Toru Shindo

Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer

OBJECTIVES Despite the advances in surgical technology, bronchopleural fistulas (BPFs) still occur and are often fatal. We studied the risk factors for BPF formation after lung cancer operation to clarify the indication of preventive bronchial stump coverage. In addition, the reliability of our methods of bronchial closure was evaluated. METHODS We reviewed 557 consecutive bronchial stumps, corresponding to 547 patients without any coverage in pulmonary resection for lung cancer between 1989 and 1998. According to nine variables, stumps that made dehiscence were compared with uneventful ones using contingency table analysis. The incidence of BPFs according to each method of bronchial closure was calculated. RESULTS BPFs developed in ten patients (1.8%). Compared with the lobar bronchus (LB), the main bronchus (MB; P<0.01; odds ratio, 23.0) and the intermediate bronchus (IB; P=0.03; odds ratio, 10.7) carried a high risk. Previous ipsilateral thoracotomy (P<0.01; odds ratio, 37.9) and preoperative chemotherapy and/or radiotherapy (P=0.02; odds ratio, 13.2) increased the risk. The incidence of BPFs with manual suture, stapling devices only, reinforcement suture at the distal side of staplers, or reinforcement suture at the proximal side of staplers was 1.8, 5.0, 1.9 and 1.0%, respectively. CONCLUSIONS The main and intermediate bronchial stumps, and the stumps in cases with previous ipsilateral thoracotomy or receiving induction therapy are prone to BPFs. Preventive coverage should be considered for these stumps. Our methods for reinforcement of stapled stumps are thought to be reliable.

Thin-section CT features of intrapulmonary lymph nodes.

Purpose The objective of this study was to evaluate CT findings of pathologically proven intrapulmonary lymph nodes (IPLNs) and discuss the utility of thin-section CT and contrast-enhanced CT. Method CT findings of 18 nodules in 14 patients with pathologically proven IPLNs were reviewed. CT scanning of the whole lung was performed contiguously with slice thickness of 10 mm. In addition, a helical scan with slice thickness of 2 mm was performed in nine patients, focusing on the nodule. Contrast-enhanced helical CT was performed in four patients, and the utility of thin section CT and contrast-enhanced CT was investigated. Results One patient had three nodules, 2 patients had two nodules, and the remaining 11 patients had a solitary nodule. All nodules were located below the level of the carina and within 15 mm of the pleura. In one case, conventional CT revealed the nodule 20 mm away from the pleura; however, the nodule attached to the major fissure was clearly revealed on thin-section CT. The size of the nodules was ≤15 mm, and the shape was round (n = 8), oval (n = 9), or lobulated (n = 1) with sharp border. One nodule demonstrated a spiculated border due to a surrounding pulmonary fibrosis on conventional CT; however, thin-section CT showed precisely a sharp border. The lobulated shape of one case histopathologically reflected a hilus of lymph node. On contrast-enhanced helical CT, all four nodules were enhanced and the degree enhancement was 36–85 HU (median 66.6 HU). Conclusion In current times, IPLNs are not uncommon lesions. We should consider IPLN in the differential diagnosis of solitary or multiple pulmonary nodules in the peripheral field and below the level of the carina. Thin-section CT showed precisely the border or relation between IPLNs and the surrounding structure. It was difficult to distinguish between IPLNs and malignant nodules from the degree of enhancement on contrast-enhanced CT. On thin-section and contrast-enhanced CT, the findings of IPLNs are not necessarily specific. Therefore, strict observation on CT is necessary; in certain cases that are increasing in size, video-assisted thoracic surgery should be considered because of their location.

Thymoma. Analysis of prognostic factors.

OBJECTIVE We evaluated the prognostic factors for thymoma that remain controversial. METHODS We studied 72 consecutive patients treated for thymoma during the period between 1966 and 1997. Recurrence-free interval rates and overall survival rates calculated by the Kaplan-Meier method were compared using log-rank test by the Masaoka stage, extent of surgical resection, histology, or associated disease(s). Multivariate analysis was performed using Coxs proportional hazards model. RESULTS Thirty-two thymomas were at Masaoka stage I, 9 at stage II, 15 at stage III, and 16 were at stage IV. There were 56 complete resections, 7 incomplete resections (2 at stage III and 5 at stage IV), and 9 biopsies (1 at stage III and 8 at stage IV). Forty-one thymomas were cortical, 16 medullary, and 15 were mixed form. Association of myasthenia gravis was found in 20 patients, and pure red cell aplasia in 7. After an average follow-up period of 103 months, the recurrence-free 5-, 10-, 15-year interval rate was 89%, 80%, 80%, respectively, and overall 5-, 10-, 15-year survival rate was 86%, 71%, 59%, respectively. Factors influencing the recurrence-free interval and overall survival included the Masaoka stage, extent of surgical resection, and association with pure red cell aplasia. Multivariate analysis revealed stage IV tumor and association with pure red cell aplasia as risk factors for recurrence. Pure red cell aplasia indicated poor prognosis for overall survival. CONCLUSIONS Masaoka stage, extent of surgical resection, and association with pure red cell aplasia were prognostic factors for thymoma. Multidisciplinary treatment for stage IV tumors and better control of pure red cell aplasia, if associated, should be investigated.

Delayed Vertical Rectus Abdominis Myocutaneous Flap for Anterior Chest Wall Reconstruction

BackgroundNot only is a radiation ulcer nonviable itself, but the surrounding irradiated tissue also shows poor healing. Therefore, healing in an irradiated field cannot be expected if a flap used for reconstruction fails even partially. For repair of radiation ulcers, a flap with a stable blood supply is required. A superiorly based vertical rectus abdominis myocutaneous (VRAM) flap is commonly used for chest wall reconstruction. Because the VRAM flap is nourished only by the superior epigastric vessels, the blood supply to the distal part of the flap often is precarious.Case ReportA case is reported in which a delayed VRAM flap was used successfully to treat a radiation ulcer on the anterior chest wall.ResultsConsecutive angiograms showed that the delay procedure augmented the blood supply to the VRAM flap. The flap showed complete take without any postoperative complications.ConclusionsA delay procedure may make the VRAM flap more reliable for anterior chest wall reconstruction. This flap may be a valuable option for reconstruction of intractable ulcers such as radiation ulcers, and may be applicable for breast reconstruction after radiation therapy.

Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: Report of a case

We present herein the case of a 50-year-old woman in whom descending necrotizing mediastinitis originating from an anterior neck abscess spread to the left upper bony thorax, resulting in osteomyelitis of the left sternocostoclavicular articulation and left partial thoracic empyema. Transcervical mediastinal irrigation and drainage was performed with aggressive antibiotic therapy, followed by resection of the left sternocostoclavicular joint and debridement of the anterior mediastinum. The patient had an uneventful postoperative course, and her left arm and shoulder mobility was well preserved.

Systemic artery-to-pulmonary artery shunt after using an omental pedicle flap

A 66-year-old man was hospitalized because of hemoptysis. Four years earlier, he had undergone an operation involving the use of an omental pedicle flap that was supplied by the right gastroepiploic artery for the treatment of empyema. Arteriography revealed that the right gastroepiploic artery communicated with the periphery of the right pulmonary artery. The right gastroepiploic artery was divided surgically.

A case of pryce type I intrapulmonary sequestration

A twenty-year-old asymptomatic man hospitalized because of a vascular murmur and abnormal shadow in the left lower lung on X-ray film. An aortogram revealed an abnormal artery arising from the descending thoracic aorta and supplying the left basal segment, which had no other pulmonary arteries. Although lung ventilation scintigraphy demonstrated reduced ventilation to the left lower lobe, bronchogram showed an almost normal bronchial tree except that peripheral branches were slightly thin. A clinical diagnosis of Pryce type I intrapulmonary sequestration was made, and left lower lobectomy was performed successfully. We have analyzed 31 cases of Pryce type I intrapulmonary sequestration in Japan. A vascular murmur is often heard, and a chest X-ray usually shows either a mass shadow or increased vascular markings. In most of those cases, an abnormal artery arises from the descending thoracic aorta and it supplies the left basal segment. Because this type of sequestration causes hemoptysis and infections, surgical intervention is indicated.

Bilateral dissemination of malignant pleural mesothelioma via iatrogenic buffalo chest: a rare route of disease progression

Buffalo chest refers to the pleuro-pleural communication that results in a single pleural cavity. Iatrogenic buffalo chest can occur following heart or heart–lung transplantation and other major thoracic surgeries. We present the case of malignant pleural mesothelioma in which iatrogenic buffalo chest after extended thymectomy caused bilateral pneumothoraces and contralateral dissemination of the disease. The free communication between bilateral pleural cavities had facilitated the rapid progression of tumor and the consequent bilateral malignant pleural effusions had made the management of disease much more difficult, leading to the early fatal outcome. To our knowledge, this is the first case of buffalo chest that was associated with bilateral malignant pleural effusions.