Tomohito Tarukawa

Intractable bronchopleural fistula caused by radiofrequency ablation: endoscopic bronchial occlusion with silicone embolic material

A 58-year-old man with primary lung cancer underwent lung radiofrequency (RF) ablation. Pneumothorax developed 12 days after lung RF ablation. Despite chest drainage for 1 month, air leakage continued through a bronchopleural fistula. Bronchial occlusion was performed with a silicone embolus, causing cessation of the air leakage.

Clinical features of primary lung cancer adjoining pulmonary bulla.

A few investigators have suggested a possible association between lung cancer and a pulmonary bulla. But its correlation is not yet fully understood. Five hundred and forty-five cases with primary lung cancer were studied retrospectively by re-evaluation of their chest computed tomography (CT)-scans. Cancer adjoined a bulla in 19 cases. In these instances, each cases clinical course, pathological findings and surgical results were investigated. All cases were men and were heavy smokers. Three of them were under 50 years of age. Bulla/cancer incidence was 3.5%. Initial symptoms were common respiratory symptoms in five cases (26.3%) and hemosputa and hoarseness in one case (5.3%), respectively. In comparison with the control group, a ratio of squamous cell carcinoma (SCC) and large cell carcinoma was significantly high (P<0.05) and differentiation of the carcinoma was poor (P<0.001). Although the pathological staging and lung function data revealed no statistical difference, the survival curve of bulla/cancer group was significantly worse (P<0.01). Primary lung cancer adjoining pulmonary bulla tends to be poor in prognosis, even if it was small in size. A low-density mass shadow adjoining the bulla should be frequently examined by CT-scans and should proceed to an exploratory thoracotomy if it have increased in size.

Surgical treatment for chronic lung and thoracic cavity infection

To avoid the complication of aspiration pneumonia, we attempted a new anterior approach of extrapleural pneumonectomy combined with thoracoplasty in four patients with chronic empyema, a bronchopleural fi stula, and severely destroyed lung. The thoracic cage was exposed by an L-shaped parasternal incision making a muscle-skin flap of the anterior chest. The anterior portions of ribs were removed at fi rst, and exfoliation was started in the mediastinal area. After detaching the lung from the mediastinum, an extrapleural pneumonectomy was completed. The backside ribs were then resected by way of the thoracic cavity. The muscle-skin flap was sutured to close the thoracic cavity completely. The procedure was tolerable for three cases. One patient died from accidental rupture of the descending aorta owing to atherosclerotic degeneration. Of the three successful outcomes, recurrence was observed in one case, although it was recurrence of malignant lymphoma associated with chronic empyema.

Principle for video-assisted thoracic surgery

We read with interest Sasaki and colleagues’ article [1] on a logical strategy to decide trocar placement and approach based on the target location in the thoracic cavity for video-assisted thoracoscopic wedge resection. We also prefer a trocar placement close to the target location, because we use Kuniyoshi P.N.CATCH (Takasago Medical Industry Co., Ltd; Tokyo, Japan. http://www. takasagoika.co.jp/index.html) to grasp it in lung parenchyma. Therefore, our trocar placement has been similar to Sasaki’s triangle principle, and invariably depends on the target location as a result. However, we have changed it to a fixed style; following learning several principles in video-assisted thoracic surgery (VATS) from Drs Kohno and Mun at the Toranomon Hospital, Tokyo, Japan. They usually perform lobectomy using three access ports (7-, 10-, and 11.5 mm diameters) without minithoracotomy [2]. This is feasible through a 308 thoracoscope, and an articulating endoscopic linear cutter and several tips that stand well in wedge resection. As well, (1) two monitors are essential, one for the operator is set up normally and another for the assistant on the opposite side who operates the thoracoscope is set up in upside-down manner to prevent mirror image problems. (2) The operator always stands on the right side of patient to maintain a wide working space for his right hand in the patient’s caudal direction. Thus, manipulation is performed with a backward approach for the right lung and with a forward approach for the left one. (3) For the right lung, trocar ports are placed at the anterior axillary line in the fourth intercostal space for the scope, at the midaxillary line in the sixth intercostal space for the right hand and at the posterior axillary line in the sixth intercostal space for the left hand. For the left lung, trocar ports are placed at the posterior axillary line in the sixth intercostal space for the scope, at the midaxillary line in the sixth intercostal space for the right hand and at the anterior axillary line in the fourth intercostal space for the left hand. In cases where the target lesion is located in the upper or lower part in the thoracic cavity, these trocar ports may be shifted one intercostal space up or downward. Because this approach makes it possible for a 308 thoracoscope to monitor everywhere in the thoracic cavity from a single fixed port, and the longitudinal direction of the image on the monitors is identical with that of the patient and is unchangeable during operation; it is particularly advantageous in cases of multiple lesions that need to be resected or in TTP type III, which the authors noted needed to be refined. Finally, although VATS is an evolving technique, and preferred approaches differ somewhat among operators [2–4], the core concept and its rationale have practical importance [5]. The author’s work is excellent and has been most informative for us.