Takuro Obama

The use of a lateral stabilizer increases the incidence of wound trouble following the Nuss procedure

BACKGROUND A lateral stabilizer has been used to prevent bar displacement during the Nuss procedure for pectus excavatum repair in pediatric patients. We experienced wound troubles in patients who had a stabilizer placed within them. The aim of this study was to examine the effect of a lateral stabilizer and other clinical factors on wound troubles after the Nuss procedure. METHODS 53 patients with pectus excavatum underwent repair by the Nuss procedure. Preoperative clinical data, operative data, and postoperative complications were examined in all patients. RESULTS A lateral stabilizer was placed in 29 of the 53 patients. Short-term results were excellent in 42 patients (79.2%). Postoperative complications involved pneumothorax requiring drainage in two patients, atelectasis in one patient, pleural effusion in three patients, deterioration of scoliosis in one patient, erythema in one patient, persistent pain in two patients, bar displacement in four patients, and local wound complications (Seroma with dermatitis due to pressure damage) in five patients. All seromas with dermatitis due to pressure damage were initially aseptic around lateral stabilizers and became infected in four patients after resection of the seroma or spontaneous perforation. Removal of both the pectus bar and lateral stabilizer was performed in two of those four patients and the lateral stabilizer was removed in the other two patients to prevent catastrophic infection such as empyema or mediastinitis. The use of a lateral stabilizer increases the incidence of wound trouble (p = 0.041). CONCLUSIONS Although the Nuss procedure has evolved into an effective method for pectus excavatum repair, the use of a lateral stabilizer increases the incidence of wound difficulties.

Need for Preoperative Computed Tomography-Guided Localization in Video-Assisted Thoracoscopic Surgery Pulmonary Resections of Metastatic Pulmonary Nodules

BACKGROUND Preoperative localization of pulmonary nodules is sometimes necessary when they are too small or distant from the surface of the visceral pleura to be detected during video-assisted thoracoscopic surgery. This study aims to present the criteria for localization and to evaluate the accuracy of the criteria. METHODS From April 2001 to March 2008, 178 patients with 224 nodules who underwent wedge resection of pulmonary metastatic nodules by video-assisted thoracoscopic surgery were reviewed retrospectively. Thirty-one patients (17.4%) including 35 nodules underwent thoracoscopic resection immediately after computed tomography-guided localization using hook wires. Criteria for preoperative localization were (1) maximum diameter of the nodule of 5 mm or less, (2) maximum diameter to minimum distance between the visceral pleura and inferior border of nodule of 0.5 or less, and (3) nodule with low-density image by computed tomography after chemotherapy. The accuracy of these inclusion criteria was statistically evaluated. RESULTS All 224 nodules were removed by wedge resection or additional segmentectomy. Nineteen nodules (54.3%) were detected in the thoracic cavity with preoperative localization. Sensitivity, specificity, positive predictive value, and negative predictive value were 11.1%, 99.5%, 66.7%, and 92.8%; 88.9%, 93.2%, 53.3%, and 99.0%; and 88.9%, 90.8%, 45.7%, and 98.9% in each preoperative finding of which a nodule met all (3 nodules), two or more (30 nodules), and one or more (35 nodules) of the three criteria, respectively. CONCLUSIONS This study suggests that preoperative localization should be considered before video-assisted thoracoscopic surgery operation if the pulmonary nodule meets two or more of our criteria.

New material for reconstruction of the anterior chest wall, including the sternum

The effectiveness of surgical resection for locally recurrent breast cancer invading the chest wall remains poorly defined. If structural stability is required, however, either autogenous tissue or prosthetic material can be used. Various materials for reconstruction of the anterior chest wall have been reported. We report the case of a 38-year-old woman who underwent resection and reconstruction of the anterior chest wall because of metastasis of carcinoma from the left breast to the sternum. We used a new material made from a ceramic prosthesis composed of a combination of hydroxyapatite and tricalcium phosphate. This is a review of a new material and method of reconstruction.

Feasibility and safety of postoperative management without chest tube placement after thoracoscopic wedge resection of the lung

PurposeThe aim of the present study was to assess the feasibility and safety of several improved criteria to avoid chest tube placement after thoracoscopic wedge resection of the lung.MethodsFrom 2000 to 2009, 333 patients who underwent thoracoscopic wedge resections of the lung were reviewed. The patients were classified into two groups: (1) the no chest tube group (NCT), consisting of 132 patients in whom chest tubes were not placed because no air leakage or bleeding during intraoperative alternative sealing test was confirmed, and (2) the chest tube placement (CTP) group, consisting of 201 patients in whom chest tubes were placed because the criteria for the nonplacement of a chest tube were not met. The clinical data and postoperative morbidity were assessed between the two groups.ResultsThe number of specimens (1.3 vs 1.5) and the endostapler cartridges used (2.5 vs 3.3), and the duration of the postoperative hospital stay (4.6 vs 6.7 days) in the NCT group were significantly lower than in the CTP group. One patient from the NCT group required chest tube insertion due to the development of late pneumothorax. However, no significant differences were found between the two groups.ConclusionsOur improved criteria are therefore considered to positively contribute to a safe and definite clinical decision regarding postoperative patient management.

Total thoracoscopic lung segmentectomy of anterior basal segment of the right lower lobe (RS8) for NSCLC stage IA (case report)

A 69-year-old woman with a pulmonary nodule in anterior basal segment of the right lower lobe (RS8) was referred to our department. The diameter of the tumor was 12 mm, and it had increased over a few months. First, video-assisted thoracoscopic lung surgery (VATS) biopsy of the pulmonary nodule was carried out. Frozen section examination of this nodule confirmed the diagnosis of bronchioloalveolar carcinoma (BAC). Segmentectomy of RS8 with lower mediastinal node dissection (ND2a-1) was performed. The intersegmental plane was identified using the intersegmental veins as landmarks and the demarcation between the resected (inflated) and preserved (collapsed) lungs. Electrocautery at 70 watts was used to divide the intersegmental plane. A vessel sealing system was used to seal and cut the pulmonary arteries. Postoperative histopathological examination revealed that the tumor was T1aN0M0 BAC, and the minimal distance between the surgical margin and the tumor edge was 15 mm. The patient was discharged from hospital on postoperative day 5 without any complications.

Extended survival of a porcine mitral bioprosthesis for 23 years: Report of a case

Limited durability is the major drawback of bioprosthetic valves, few of which survive for as long as 20 years. We report herein the case of a patient we recently encountered in whom a bioprothesis lasted for 23 years. To our knowledge, this is only the second case of such long survival. The patient was a 56-year-old man who was urgently admitted to our hospital with acute mitral regurgitation, 23 years after undergoing mitral valve replacement with a porcine bioprosthesis. Acute leaflet tears were found to be the cause of the mitral incompetence and the xenograft was successfully replaced with a mechanical valve. We believe that when reoperation is thought to carry a low risk, prophylactic surgery might be justified, even in patients without symptoms.

Right parasternal minithoracotomy for repair of atrial septal defect.

Abstract  Various surgical approaches for repair of atrial septal defect (ASD) have recently been introduced for superior cosmetic and less invasive results. A technique for repair of isolated ASD through a small right parasternal minithoracotomy is described. In spite of the smaller incision, there is no need to use femoral cannulation or video‐assisted endoscopy. This approach is simple, less invasive, and cosmetic. We believe that right parasternal minithoracotomy is a suitable alternative to a median sternotomy for ASD closure, especially in young male patients.