Tadasu Kohno

Costs of videothoracoscopic surgery versus open resection for patients with of lung carcinoma.

The costs of videothoracoscopic procedures for patients with lung carcinoma were compared with those of patients who underwent open thoracotomy in Japan.

Video-assisted thoracic surgery for clinical stage I lung cancer in octogenarians.

BACKGROUND The purpose of this retrospective study was to investigate the value of video-assisted thoracic surgery (VATS) for clinical stage I lung cancer in octogenarians. METHODS From April 1999 to December 2006, 55 consecutive patients aged older than 80 years with clinical stage I lung cancer underwent VATS pulmonary resection. We reviewed preoperative and perioperative data, morbidity, and mortality occurring within 30 days or before discharge, and long-term survival. RESULTS There were 35 men and 20 women with a mean age of 82.7 years (range, 80 to 89 years). The surgical procedures using VATS comprised 37 lobectomies, one bilobectomy, and 17 sublobar resections (7 segmentectomies, 10 wedge resections). Two lobectomies (3.6%) were converted to thoracotomy due to bleeding. The cancer was adenocarcinoma in 38 patients (62.3%), squamous cell carcinoma in 12 (19.7%), bronchioloalveolar carcinoma in 3 (4.9%), large-cell neuroendocrine carcinoma in 3 (4.9%), and others in 4 (6.6%). Postoperative complications occurred in 14 patients (25.6%), including bacterial pneumonia in 4 (7.3%), mild arterial arrhythmia in 3 (5.6%), air leak lasting more than 7 days in 3 (5.6%), pulmonary dysfunction that needed oxygen therapy in 2 (3.6%), aggressive interstitial pneumonia in 1 (1.8%), and six other minor complications. There were two operative deaths (3.6%), one due to bacterial pneumonia on postoperative day 132, and another due to aggressive interstitial pneumonia on postoperative day 105. Median hospital stay was 8.0 days. Median follow-up was 49 months. The actuarial survival rate of the 55 patients was 76.4% at 3 years and 65.9% at 5 years. CONCLUSIONS With appropriate selection of patients and procedures, VATS can be safely used for lung cancer in octogenarians with good prognostic results.

Application of a new tactile sensor to thoracoscopic surgery: Experimental and clinical study

BACKGROUND We developed a new tactile sensor that could quantify the hardness of objects as changes in the resonance frequency of the sensor (delta f). We have applied it to thoracoscopic operations for the localization of small invisible nodules in the lung. METHODS When the sensor probe was moved over the lung surface, a delta f curve was depicted on the computer screen. When the sensor tip reached a point directly above a hard object, a sudden upward jump of the delta f curve was evoked. After experimental studies using pigs, the sensor was applied in 8 patients. More recently we produced a needle sensor to distinguish small nodules from bronchi that may evoke similar upward jumps of the delta f curve. Eight nodules and four bronchi in resected human lungs were probed directly using this sensor. RESULTS In all of the patients, the hardness of various thoracic structures could be quantified. A total of 10 nodules were found using the sensor and resected thoracoscopically. The needle sensor distinguished nodules from bronchi, as the mean delta f of the bronchial walls (-64 +/- 45.9 Hz) was significantly higher than that of nodules (-526 +/- 168 Hz, p < 0.001). CONCLUSIONS Thoracoscopic detection of small and invisible pulmonary nodules using our new tactile sensor is feasible.

Magnetic resonance-thoracic ductography: imaging aid for thoracic surgery and thoracic duct depiction based on embryological considerations

PurposeWe describe the optimal protocol of magnetic resonance-thoracic ductography (MRTD) and provide examples of thoracic ducts (TD) and various anomalies. The anatomical pathway of the TD was analyzed based on embryological considerations.MethodsA total of 78 subjects, consisting of noncancer adults and patients with esophageal cancer and lung cancer, were enrolled. The MRTD protocol included a long echo time and was based on emphasizing signals from the liquid fraction and suppressing other signals, based on the principle that lymph flow through the TD appears hyperintense on T2-weighted images. The TD configuration was classified into nine types based on location [right and/or left side(s) of the descending aorta] and outflow [right and/or left venous angle(s)].ResultsMRTD was conducted in 78 patients, and the three-dimensional reconstruction was considered to provide excellent view of the TD in 69 patients, segmentalization of TD in 4, and a poor view of the TD in 5. MRTD achieved a visualization rate of 94%. Most of the patients had a right-side TD that flowed into the left venous angle. Major configuration variations were noted in 14% of cases. Minor anomalies, such as divergence and meandering, were frequently seen.ConclusionMRTD allows noninvasive evaluation of TD and can be used to identify TD configuration. Thus, this technique is considered to contribute positively to safer performance of thoracic surgery.

Hemodynamic effects of carbon dioxide insufflation under single-lung ventilation during thoracoscopy.

BACKGROUND The hemodynamic effects of carbon dioxide insufflation under single-lung ventilation were studied in 22 consecutive thoracoscopic harvests of the left internal mammary artery, which was used for minimally invasive coronary artery bypass grafting. METHODS An electrocardiograph, arterial catheter, Swan-Ganz catheter, and transesophageal echocardiograph were used to monitor seven hemodynamic variables. Baseline data were obtained during ventilation of both lungs and the measurements were repeated after the left lung was collapsed and at 5 and 30 minutes after hemithorax insufflation with low-flow (2 to 3 L/minute) carbon dioxide gas was begun. The intrapleural pressure was maintained at 8 to 10 mm Hg. RESULTS Thoracoscopic harvest of the internal mammary artery was completed in all cases with a mean insufflation time of 44+/-12 minutes. There were no significant changes in the mean arterial pressure, heart rate, cardiac index, and left ventricular ejection fraction throughout the procedure, whereas the central venous pressure, mean pulmonary arterial pressure, and pulmonary capillary wedge pressure (p < 0.05 for each variable) during insufflation. CONCLUSIONS Low-flow carbon dioxide insufflation into the left hemithorax with an intrapleural pressure of 8 to 10 mm Hg under selective right-lung ventilation does not compromise the human heart with normal to moderately depressed function and can be an efficacious adjunct in specific thoracoscopic procedures.

Results from surgical treatment for thymoma. 43 years of experience.

OBJECTIVE The biological behavior of thymoma and its prognosis after surgical intervention remain still controversial. The efficacy of surgical treatment for thymoma was investigated by examining long-term follow-up data. SUBJECTS AND METHODS Follow-up data for patients undergoing surgical resection of histopathologically-confirmed thymoma between 1954 and 1997 were obtained and were retrospectively analyzed. Clinical staging was based on Masaokas staging system, and histological classification on Rosais proposed criteria. RESULTS Data for 140 patients were collected. Sixty-four patients had stage I, 32 had stage II, 28 had stage III, and 16 had stage IV thymoma. There were significant differences in survival between patients with stage I and stage III, stage I and stage IV and stage II and stage III disease, but not between those with stage I thymoma and stage II thymoma. No significant difference in survival was observed between the 56 patients with myasthenia gravis (MG) and the 84 without MG. The 38 patients classified as having a predominantly-epithelial thymoma had a poorer prognosis than the 41 with a predominantly-lymphocytic thymoma. Until 1975, there were four patients with stage I thymomas who later showed recurrence, compared with 21 among those with stage II, III and IV diseases. Since 1976, extended thymectomy with thymomectomy under median sternotomy has been adopted as the standard operation for a thymoma, and there has been no recurrence in stage I patients. CONCLUSIONS Patients with stage III or IV invasive thymoma have a poorer prognosis and a higher recurrence rate than those with encapsulated thymoma, and patients with a predominantly-epithelial thymoma have a poorer prognosis than those with a predominantly-lymphocytic thymoma. Extended thymectomy with thymomectomy under median sternotomy can be considered as adequate treatment for a stage I thymoma. Myasthenia gravis does not appear to affect the prognosis of patients with a thymoma.

Excellent survival in a subgroup of patients with intrapulmonary metastasis of lung cancer

BACKGROUND Recently, intrapulmonary metastases in non-small cell lung cancer have been considered to have less influence on prognosis than extrapulmonary metastases. We report a subgroup found among patients with intrapulmonary metastases showing a good prognosis. METHOD A retrospective study was performed on 236 consecutive patients with non-small cell lung cancer who underwent surgical resection of their tumors. Intrapulmonary metastases were found histopathologically in 50 of them, and their clinicopathologic features were investigated. RESULTS Analysis of postsurgical results revealed a subgroup of patients showing excellent prognosis (n = 15). They had well-differentiated adenocarcinomas with bronchioloalveolar spread and pT1-2 N0, without vascular or lymphangitic invasion. Their actuarial 5-year survival rate was 100%, with a mean survival interval to date of 28 months. However, none of the other 35 patients survived for 5 years, with a mean survival interval to date of 11 months. CONCLUSIONS We have clarified that patients with histopathologically diagnosed intrapulmonary metastases from non-small cell lung cancer do not constitute a homogeneous group. Pulmonary metastases with good prognosis, which are considered to be hematogenous metastases, may be benign lesions such as adenomatous or atypical adenomatous hyperplasias mimicking malignant tumors.

Safe and Effective Minimally Invasive Approaches for Small Ground Glass Opacity

BACKGROUND Popularized computed tomography physical check up results in an increasing number of patients with ground glass opacity (GCO) lesions of which management has not been established yet. METHODS From January 2004 to December 2008, 738 patients underwent pulmonary resection for primary lung cancer, and 96 (13.0%) with resected GGO lesions were included in this study. Pure GGO lesions sized less than 10 mm are monitored until they grow bigger or develop a core. Three-port video-assisted thoracic lobectomy with systematic lymph node dissection is indicated when the lesion diameter exceeds 15 mm or is invasive, and segmentectomy is indicated when the tumor diameter is 10 to 15 mm. Wedge resection is indicated when the tumor is peripherally located. RESULTS There was no procedurally related mortality or morbidity. There were 9 papillary adenocarcinomas or invasive bronchioloalveolar carcinomas, 75 noninvasive bronchioloalveolar cell carcinomas, 7 atypical adenomatous hyperplasias, and 5 organizing pneumonias. No local recurrence was observed. CONCLUSIONS Several pathologies are included in GGO lesions, and the video-assisted thoracic approach seems to be one of the best options in their management.

Video-assisted thoracic surgery for pulmonary aspergilloma

The purpose of this retrospective study was to review our experience with video-assisted thoracic surgery (VATS) for pulmonary aspergilloma. The patients (n=20) were aged 62+/-12 years, and eight (40%) were aged 70 years or more. The disease types were simple aspergilloma (SA) in six patients and complex aspergilloma (CA) in 14. The surgical procedures performed were lobectomy in 14 patients, segmentectomy in two, and wedge resection in four. The operation time was shorter (143+/-69 min vs. 216+/-85 min; P=0.08) and the blood loss was less (10+/-17 ml vs. 307+/-346 ml; P<0.01) for patients with SA than those with CA. Postoperative death occurred in one patient with CA who developed a bronchial stump fistula (30-day mortality; 5.0%). During follow-up, three patients died from other non-disease-related causes, and the remaining 17 patients survived without recurrence. The 5-year survival rate was 89%. In suitable cases, VATS for pulmonary aspergilloma may not be inferior to open surgery with regard to safety and efficacy. In particular, SA is considered to be a good indication for VATS.

Diagnostic localization of ectopic parathyroid lesions: developmental consideration

Parathyroid glands arise from the third and fourth pharyngeal pouches. Parathyroid lesions sometimes develop ectopically. The aim of this article is to illustrate the knowledge of pharyngeal apparatus development to assist with diagnostic localization of ectopic parathyroid lesions. We retrospectively reviewed charts of 23 patients who received a diagnosis of ectopic parathyroid lesions. The ectopic lesions were widely distributed; cranially lesions were located on the carotid bifurcation, caudally in the right paraaortic region, ventrally on the surface of the sternohyoid muscle, and dorsally in the paraesophageal region. In most cases, parathyroid tissues were associated with structures related to the third or fourth pharyngeal pouches that traveled to regions where the ectopic lesions ultimately developed. In a few cases, lesions were not associated with these pouches and might have developed from parathyroid tissue that migrated due to an anomalous pathway of parathyroid travel. When patients present without entopic lesions, the presence of ectopic lesions should be evaluated based on an understanding of the developmental mechanisms of parathyroid glands and the frequency with which ectopic lesions have been found in specific locations. Systematic diagnosis can minimize the frequency with which ectopic lesions are missed during clinical care and maximize their accurate localization.