Takuji Fujinaga

Adverse events of pulmonary vascular stapling in thoracic surgery

OBJECTIVES The use of staplers for thoracic surgery has been widely accepted and regarded as a safe procedure. However, adverse events (AEs) of stapling are occasionally experienced. The aim of this retrospective study was to analyse the AEs of stapling in pulmonary vascular surgery. METHODS A retrospective multi-institutional review was conducted by the 29 institutions of the Central Japan Lung Cancer Surgery Study Group. All staplings of the pulmonary artery (PA) and vein in thoracic surgery were reviewed during the research period. RESULTS Stapling of the PA and vein was performed 3393 times. The total number of AEs related to stapling was nine (0.27%). Eight events occurred intraoperatively and one occurred immediately after the operation. Intraoperative AE occurred more frequently than postoperative AE. AE in the PA occurred more frequently than in the pulmonary vein. The intraoperative AEs were oozing (n=3), stapling failure (n=2), laceration of the peripheral vasculature at compression (n=2) and technical injury of the vasculature at insertion (n=1). The causes of AEs were reported to be tissue fragility (n=3), stapler rocking during stapling (n=2), stapler-tissue thickness mismatch (n=2) and technical failure (n=1). The only postoperative AE was staple line rupture of the PV stump. No relationship was seen between the incidence of AE and cartridge colours, compression types of staplers or numbers of staple lines. CONCLUSIONS Generally, stapling of the pulmonary vasculatures in recent thoracic surgery has been safe. Furthermore, the knowledge of the possible risks of pulmonary vascular stapling may help to decrease the AEs of stapling.

The importance of pleural integrity for effective and safe thoracic paravertebral block: a retrospective comparative study on postoperative pain control by paravertebral block.

OBJECTIVES Recently, paravertebral block (PVB) has been reported to be an effective analgesic modality for post-thoracotomy pain, but there is no consensus on how thoracic PVB can be more effective. Our hypothesis that intact pleura has a significant impact on the analgesic effectiveness of thoracic PVB was evaluated. METHODS Data of patients who underwent general thoracic surgery [thoracotomy or video-assisted thoracic surgery (VATS)] and paravertebral catheterization at Nagara Medical Center between April 2010 and March 2013 were collected. To compare the frequency of non-steroidal anti-inflammatory drugs taken as well as the usage of rescue pain medications between patients with pleural disruption and those without, data were analysed after matching on propensity scores. Covariates for match estimation were age, sex, body mass index, American Society of Anesthesiologists score, diagnosis, operative details and local anaesthesia infused. RESULTS There were 278 patients who underwent general thoracic surgery and paravertebral catheterization. The propensity score-matching process created 78 matched patients with pleural disruption and those without. Based on the propensity score matching, a significant increase in the frequency of non-steroidal anti-inflammatory drugs taken on postoperative day 1 and in the usage of rescue drugs was observed in patients with pleural disruption. CONCLUSIONS According to our analysis, creating a sub-pleural space without pleural disruption is essential for quality thoracic PVB.

Chest Wall Angiolipoma Complicating Von Recklinghausen Disease

We present the case of an 18-year-old man with chest wall angiolipoma and a medical history of von Recklinghausen neurofibromatosis. The chest wall tumor was originally detected during an evaluation for chest pain. For diagnostic and therapeutic purposes, video-assisted thoracoscopic resection was performed, and the tumor was histopathologically confirmed to be an angiolipoma. Chest wall angiolipoma is exceptionally rare. Only two cases have been reported in the English literature, with no reports regarding chest wall angiolipoma in a patient with von Recklinghausen disease.

A case of surgery for congenital esophagobronchial fistula accompanied by a destroyed lung

Congenital esophagobronchial fistula (EBF) is rarely seen in adults. We report a case of EBF detected in adulthood with a destroyed lung. A 67-year-old man experienced repeated pneumonia during his childhood. Since the age of 38, he had often suffered from bloody phlegm and always had a cough and sputum during oral intake. Before cardiac surgery for atrial fibrillation and valvular disease, computed tomography (CT) detected bronchiectasis, which could cause pulmonary bleeding during heart surgery, and the patient was introduced to our hospital for lung resection. A fistula between the esophagus and the right lower lung lobe was found using CT, esophagoscopy, and esophagography. Contrast CT and angiography revealed an abnormal artery branching from the inferior phrenic artery into the lobe. As indicated by intraoperative findings, the middle and lower lobes had strongly adhered to chest wall and diaphragm, but we located the fistula easily without adhesion to the surroundings, severed it using an automatic stapler, and resected the middle and lower lobes. The symptoms disappeared immediately, and the patient was uneventfully discharged.The diagnosis of congenital EBF was established with intraoperative findings and pathological exam. The existence of pulmonary sequestration was suggested because of the long-term absence of any symptoms during his adulthood, the tract of the EBF running into the lung, not directly into the bronchus, and a septum pathologically detected in the right lower lobe. A congenital EBF should be considered for differential diagnosis in cases of limited bronchiectasis in elderly people.

A patient with malignant pleural mesothelioma complicated with Dubin–Johnson syndrome treated with cisplatin/pemetrexed combination therapy: the need to consider mutation to the ATP-binding cassette-C2 gene and the pharmacokinetics of pemetrexed

Dubin–Johnson syndrome is a form of constitutional jaundice induced by a mutated ATP-binding cassette-C2 (ABCC2) gene. The ABCC2 gene is involved in the excretion of drugs. We recently treated a patient with malignant pleural mesothelioma complicated with Dubin–Johnson syndrome with cisplatin/pemetrexed combination therapy. One-third of the dose compared to the standard dose of pemetrexed was administered during the first course. We increased the dose of pemetrexed in stages after evaluating the patient for adverse effects. Cisplatin was combined beginning in the fourth course. The adverse effects of cisplatin/pemetrexed combination therapy were slight, and the patient exhibited a partial response. We measured the blood concentration and analyzed the pharmacokinetics of pemetrexed. As a result, the excretion of pemetrexed was found to be good, and no delay of excretion was observed compared to that in normal patients. It was previously reported that the ABCC2 gene is expressed in the kidneys. However, it appears that ABCC2 might not be related to the excretion of pemetrexed. These results suggest that standard dose cisplatin/pemetrexed combination therapy could be conducted for patient with malignant pleural mesothelioma complicated with Dubin–Johnson syndrome from the first course.

A case of thoracolithiasis diagnosed thoracoscopically.

INTRODUCTION Thoracolithiasis is quite rare with only 18 cases reported in the literature. PRESENTATION OF CASE The 65-year-old female was referred to us for the abnormality on the chest X-ray. The serial computed tomographic (CT) scans showed a mobile calcified nodule of about 10mm in diameter. Exploratory thoracoscopy was performed. A 15mm pearl-like pleural stone was removed with uneventful postoperative course. DISCUSSION Thoracolithiasis is very rare, and its etiology as well as its epidemiology still remains to be unclear. Preoperative diagnosis is always difficult. However, specific radiological findings could let us recognize the probability of that lesion and avoid unnecessary major operation. CONCLUSION Thoracolithiasis should never be overlooked as a differential diagnosis in a pulmonary calcified nodule.

Low incidence of and mortality from a second malignancy after resection of thymic carcinoma

OBJECTIVES Previous studies have suggested that a second malignancy often develops after resection of thymoma; however, it remains unknown whether this is applicable to thymic carcinoma. METHODS A retrospective chart review was performed based on our multi-institutional database of resected thymic epithelial tumours between 1991 and 2016. A second malignancy was defined as newly diagnosed after thymic tumour resection. The cumulative incidence of and related death from a second malignancy after thymic and neuroendocrine carcinoma resections were estimated using a competing risk model and were compared to those of patients undergoing a thymoma resection. RESULTS Two hundred and thirty-eight patients were identified (thymic carcinoma 59; thymoma 179). A second malignancy developed in 1 patient (1.7%) with thymic carcinoma and in 17 patients (9.5%) with thymoma. Deaths from second malignancies were noted in 7 patients with thymoma. There was a tendency towards a lower cumulative incidence of and a lower cumulative death from a second malignancy after thymic carcinoma resection (P = 0.139 and P = 0.20, respectively) than after thymoma resection. The cumulative incidence of a second malignancy in patients with thymic carcinoma was 2.8% at 5 years and at 10 years (8.0% at 5 years and 11.8% at 10 years in patients with thymoma). CONCLUSIONS After resection of thymic and thymic neuroendocrine carcinoma, the probability of developing a second malignancy, as well as mortality from a second malignancy, is very low. A prospective study with a larger sample size is required to validate our results.

A case of solitary pulmonary metastasis of choroidal melanoma with an exceptionally long disease-free period

INTRODUCTION Choroidal melanoma is the most common primary malignant intraocular tumor in adults. And its metastatic spread has been considered to be hematogenous with the liver being the most common site, and a solitary pulmonary metastasis without hepatic involvement is quite rare. PRESENTATION OF CASE We report the case of a 61-year-old woman with a solitary pulmonary metastasis from choroidal melanoma, which had been originally treated with enucleation 13 years ago. Video-assisted thoracoscopic surgery (VATS) right upper lobectomy was performed for the right upper lobe tumor, which was histopathologically confirmed to be metastatic choroidal melanoma. DISCUSSION Our case is quite unusual in 2 points; firstly, a solitary pulmonary metastasis without hepatic involvement is rare. Secondly, this mode of metastasis with an exceptionally long disease-free period (13 years) is also rare. CONCLUSION A pulmonary metastasis from choroidal melanoma is described with reference to relevant literature.