Shuji Haraguchi

Video-assisted lobectomy in elderly lung cancer patients

OBJECTIVES We evaluated the pre-, intra- and postoperative outcome of video-assisted thoracic surgery lobectomy in elderly lung cancer patients to determine what factors may be disadvantageous. METHODS From June 1982 to May 2000, 707 patients underwent pulmonary resection for primary lung cancer. Of these, 87 patients with t1-2 peripheral lung cancer underwent lobectomy and postoperative pulmonary function tests and postoperative conditions at an average of 2.3 months postoperatively. Of these, 52 underwent video-assisted thoracic surgery lobectomy since 1994 and 35 lobectomy by standard thoracotomy. RESULTS Video-assisted thoracic surgery lobectomy offered advantages in blood loss, chest wall damage, and minimal performance deterioration status. The percent vital capacity, percent forced expiratory in 1 second, and percent maximum ventilatory volume were well preserved in patients who underwent video-assisted thoracic surgery lobectomy. Multivariate logistic regression analysis identified operation duration as an independent risk factor in morbidity and operative procedure as an independent risk factor in performance deterioration. In stage IA and IB patients, 3-year-survival was 92.9% and 5-year survival 53.8% in those undergoing lobectomy by standard thoracotomy and 84.2% at 3 years and 60.1% at 5-years in those undergoing video-assisted thoracic surgery lobectomy. CONCLUSION We thus consider video-assisted thoracic surgery lobectomy in this age group to be an effective procedure, but the long surgical duration is a risk factor in a poor clinical outcome.

LOBECTOMY BY VIDEO-ASSISTED THORACIC SURGERY FOR PRIMARY LUNG CANCER : EXPERIENCES BASED ON PROVISIONAL INDICATIONS

A retrospective study on compromised patients who underwent a lobectomy by a standard thoracotomy for stage I non-small cell lung cancer revealed them to show a poor prognosis and quality of life due to their deteriorated physical conditions. Therefore, a lobectomy by video-assisted thoracic surgery (VATS lobectomy) was performed on some of these patients according to the provisional indications based on our retrospective study which indicated that it may be beneficial. Fourteen patients underwent VATS lobectomies (VATS group). Sixteen patients who underwent lobectomy by standard thoracotomy (ST group) were compared with those of the VATS group as historical controls. Although the mean operating time for the VATS group was longer than that for the ST group, there was no significant difference. The mean amount of blood loss for the VATS group was significantly less than that for the ST group. The mean maximal postoperative serum CPK level of the VATS group was slightly less than that of the ST group. A significant difference was observed regarding the changes in performance status both before and after operation between the VATS group and the ST group. We thus considered a VATS lobectomy to be beneficial for aged patients, especially in those with restricted physical conditions.

Resection of Sternal Tumors and Reconstruction of the Thorax: A Review of 15 Patients

PurposeWe report our experience of resecting sternal tumors, followed by reconstruction of the skeletal and soft-tissue defects, and discuss the usefulness of sandwiched Marlex and stainless-steel mesh.MethodsFifteen patients underwent resection of a sternal tumor and chest wall reconstruction with autologous bone grafts, sandwiched Marlex and stainless-steel mesh or a titanium plate, and musculocutaneous flaps. The sternal tumors were from locally recurrent breast carcinoma in ten patients, metastasis from other organs in three, and primary chondrosarcoma in two.ResultsAll patients were extubated without paradoxical respiration just after surgery. There was no operative mortality. A wound infection developed in the acute phase after a sandwiched Marlex and stainless-steel mesh reconstruction in one patient. A second repair with Marlex and stainless-steel mesh was required in two patients; for flail chest after an autologous bone graft in one; and following re-recurrence of breast carcinoma in another patient who had undergone a musculocutaneous flap repair. No signs of breakdown, dislodgment, severe depression, or deformity were seen in any of the six patients who underwent reconstruction with Marlex and stainless-steel mesh during a median follow-up period of 56 months.ConclusionsWide resection of sternal tumors provides good local control. Reconstruction with Marlex and stainless-steel mesh seems to be the most effective technique for repairing a wide anterior chest wall defect.

Prediction of the Postoperative Pulmonary Function and Complication Rate in Elderly Patients

Abstract We analyzed the risk factors predisposing elderly patients to develop postoperative respiratory complications (PRCs) and investigated the possibility of predicting the postoperative pulmonary function and PRC rate. The postoperative pulmonary functions were predicted according to a simplified system, which we developed using plain chest roentgenograms from patients with primary lung cancer. Both univariate and multivariate analyses of PRCs were performed in 39 elderly patients with lung cancer from July 1982 to March 1991 (the early period). Based on the results obtained, the permissible extent of lung resection to achieve a predicted postoperative % forced expiratory volume in 1 s (ppo%FEV1.0) and a predicted postoperative % vital capacity (ppo%VC) of more than 55% was selected as the basic criteria for undergoing such an operation after April 1991 (the recent period). A ppo%FEV1.0 and/or ppo%VC of 55% or less was the most significant risk factor for developing PRCs. The PRC rate decreased from 33.3% to 9.8% (P = 0.0251) and the operative mortality rate decreased from 10.3% to 0%. The survival rates for stage I, II, and III cases were not significantly different between the early and recent periods. Decisions made on the operability and the permissible extent of lung resection based on our system using plain chest roentgenograms therefore appeared to reduce the PRC rate and operative mortality rate in elderly patients.

Determining the plasma concentration of ketamine that enhances epidural bupivacaine-and-morphine-induced analgesia.

N-methyl-d-aspartate (NMDA) receptor antagonists enhance opioid-induced analgesia. The plasma concentration of ketamine, an NMDA receptor antagonist that enhances epidural morphine-and-bupivacaine-induced analgesia, is not known. We examined 24 patients with lung carcinoma or metastatic lung tumor who underwent video-assisted thoracic surgery in a placebo-controlled, double-blind manner 4 h after emergence from anesthesia. The morphine + ketamine group (n = 8) and morphine + placebo group (n = 8) received 5 mL volume of 2.5 mg morphine and 0.25% bupivacaine and the placebo + ketamine group (n = 8) received 5 mL volume of saline and 0.25% bupivacaine epidurally at the end of skin closure. Four hours after this anesthesia, in the morphine + ketamine and placebo + ketamine groups, ketamine was administered to successively maintain a stable plasma ketamine concentration of 0, 10, 20, 30, 40, and 50 ng/mL by a target-controlled infusion device, and patients assessed the levels of pain at rest, pain on coughing, somnolence (drowsiness), and nausea using a 100-mm visual analog scale (VAS). In the morphine + placebo group, a placebo (saline) was similarly administered instead of ketamine. In the morphine + ketamine group, the VAS scores for pain at rest and pain on coughing significantly decreased on ketamine administration at a plasma concentration of 20 ng/mL or larger compared with the respective baseline VAS scores (P < 0.05 each). In the placebo + ketamine group, the VAS scores for pain at rest and pain on coughing did not significantly change at any plasma concentration of ketamine as compared to the morphine + placebo group. In the morphine + ketamine group, a plasma concentration of ketamine larger than 20 ng/mL did not further reduce VAS scores for pain at rest and pain on coughing. The VAS scores for drowsiness were comparable among the three groups at any plasma concentration of ketamine. Ketamine at a plasma concentration of 20 ng/mL or larger may enhance epidural morphine-and-bupivacaine-induced analgesia. As an adjunct with epidural morphine-and-bupivacaine and considering the safety of small doses, the minimal plasma concentration of ketamine given IV may be approximately 20 ng/mL.

Pulmonary carcinosarcoma: Immunohistochemical and ultrastructural studies

A case of pulmonary carcinosarcoma in a 68‐year‐old male patient is reported. The tumor in the resected left upper lobe extended mainly endobronchially, invading the normal bronchial lumina and mucosa. The carcinomatous component consisted of poorly differentiated squamous cell carcinoma and was mainly located in the periphery of the tumor nests. The sarcomatous component consisted of chondrosarcoma and was mainly located in the center of the tumor nests. Tumor cells in the sarcomatous component reacted with anti‐S‐100 protein antibody and were surrounded with abundant homogeneous extracellular matrix staining positively with Alcian blue. The transition from the carcinomatous component to the sarcomatous component appeared to be very smooth. The tumor cells in both the carcinomatous and sarcomatous components reacted with anti‐epithelial membrane antigen antibody. Ultrastructurally, the tumor cells with tonofibrils in the carcinomatous component were apposed and connected to each other by desmosomes. By contrast, in the sarcomatous component, the tumor cells had well‐developed and dilated rough endoplasmic reticulum and were arranged loosely in a myxomatous matrix. Some tumor cells in the sarcomatous component had occasional tonofibrils, and were apposed and connected to each other by desmosome‐like structures. It is shown for the first time, ultrastructurally and immunohistochemically, that the tumor cells in the sarcomatous component of pulmonary carcinosarcomas have features of both epithelial and mesenchymal cells. It is suggested that the sarcomatous component in the present case is derived from the carcinomatous component.

Thoracoscopic Enucleation of a Submucosal Bronchogenic Cyst of the Esophagus : Report of Two Cases

Thoracoscopic enucleation of a bronchogenic cyst of the esophagus was successfully performed in two cases. The first patient was a 26-year-old female complaining of dysphagia and retrosternal discomfort. The second patient was a 56-year-old female complaining of retrosternal discomfort. A close examination revealed a cystic lesion compressing the esophagus in both cases. Three trocars were employed under general anesthesia. Thoracoscopy offering excellent visualization allowed us to perform a precise anatomical dissection between the muscle layer and the mucosa. Both patients recovered uneventfully and the symptoms disappeared postoperatively. Thoracoscopic surgery is thus considered to be beneficial for the treatment of a benign esophageal tumor because of the small chest wall entry, which might positively contribute to a favorable postoperative course.

Characteristics of Multiple Primary Malignancies Associated with Lung Cancer by Gender

Background: There are gender differences in multiple primary malignancies associated with lung cancer (MPMLC) in terms of clinical characteristics. However, the importance of these differences in the management of patients has not been clarified. Objective: Differences in characteristics affected by gender were investigated in MPMLC to identify factors important for the proper management of the patients. Methods: Univariate and multivariate analyses were performed between 82 male and 34 female patients with MPMLC treated from August 1982 to March 2002. Results: In univariate analysis, the numbers of smokers or ex-smokers, smoking-related cancer and synchronous multiple primary malignancies were significantly increased in males with MPMLC (p < 0.0001, p < 0.05 and p < 0.05, respectively). In multivariate analysis, synchronous multiple primary malignancies and the number of smokers or ex-smokers were significantly different between male and female MPMLC. Gastric, lung and colon cancers were major constituents in male MPMLC, and 40.2% of all malignancies were smoking-related cancers. On the other hand, breast and uterine cancers were major constituents in female MPMLC, and only 20.6% of all MPMLC were smoking-related cancers. Conclusions: Male patients with MPMLC demonstrated significant smoking history and synchronous multiple primary malignancies, indicating the need for different approaches to properly manage and follow up male versus female MPMLC patients.

Resection of sternal metastasis from endometrial carcinoma followed by reconstruction with sandwiched marlex and stainless steel mesh: report of a case.

We report the successful resection of sternal metastasis from endometrial carcinoma, followed by reconstruction of the chest defect, in an 87-year-old woman. We performed subtotal sternectomy and concurrent resection of the ribs and overlying soft tissue. The skeletal defect was then reconstructed with sandwiched Marlex and stainless steel mesh, and soft tissue coverage was accomplished by using a pectoralis major advancement flap. The patient had an uneventful postoperative course with no sign of recurrence during 5 years of follow-up. Thus, reconstruction with Marlex and stainless steel mesh could be an effective technique for preventing paradoxical movement of the thorax and protecting the intrathoracic organs.

Ciprofloxacin Penetration into the Pulmonary Parenchyma in Japanese Patients

PurposeTo assess the degree of penetration of intravenous (i.v.) ciprofloxacin into the lung parenchyma resected for lung carcinoma in Japanese patients.MethodsCiprofloxacin was given i.v. over 1 h to ten Japanese patients with non-small cell lung carcinoma. We took 1 g of normal lung parenchyma and 1 ml of blood serum for analysis when the lung was resected. Ciprofloxacin concentrations were determined by high-performance liquid chromatography.ResultsThe mean time from the end of ciprofloxacin administration to lung resection was 135 ± 55 min (range, 75–223 min). The mean concentrations of ciprofloxacin in the lung parenchyma and blood serum were 4.9 ± 2.0 µg/g (range, 2.1–7.9) and 1.5 ± 0.7 µg/ml (range, 0.8–2.7). The mean tissue per serum concentration ratio was 3.6 ± 2.2 (range, 1.9–8.7).ConclusionThe concentrations of ciprofloxacin in the lung parenchyma after i.v. administration in Japanese patients were above the minimal inhibitory concentration for bacteria from at least 75 min until 4 h later.