Toshiteru Nagashima

Video-assisted thoracic lobectomy with bronchoplasty for lung cancer, with special reference to methodology.

Few studies have described video-assisted thoracic surgery (VATS) to bronchoplasty with pulmonary resection. Here, we report the successful implementation of VATS bronchoplasty, as determined retrospectively. Between 2005 and 2010, 362 patients underwent elective lung resection for malignant or benign lung tumors. Of these patients, VATS lobectomy with bronchoplasty was performed in seven patients (four men, three women; median age, 72.9 years). The medical records were retrospectively reviewed. Of the seven patients, six had primary lung cancer (PLC), and one had metastatic cancer of the lung. The surgical procedures were lobectomy with wedge bronchoplasty. The patients with PLC also underwent mediastinal or hilar lymph node dissection. The median total operating time was 230 min, and the median blood loss was 152 ml. The median postoperative hospital stay was seven days, without major postoperative complications. The most important feature of the described method is that the surgeon mainly observes the operative field directly, through a working wound; the surgical team observes via a monitor. An advantage for the surgeon is the ability to use the same instruments in VATS as are used in conventional thoracotomy, as well as the same suturing techniques in vascular reconstruction, especially involving the pulmonary artery.

Establishment of a human lung cancer cell line with high metastatic potential to multiple organs: gene expression associated with metastatic potential in human lung cancer

Convenient and reliable multiple organ metastasis model systems might contribute to understanding the mechanism(s) of metastasis of lung cancer, which may lead to overcoming metastasis and improvement in the treatment outcome of lung cancer. We isolated a highly metastatic subline, PC14HM, from the human pulmonary adenocarcinoma cell line, PC14, using an in vivo selection method. The expression of 34,580 genes was compared between PC14HM and parental PC14 by cDNA microarray analysis. Among the differentially expressed genes, expression of four genes in human lung cancer tissues and adjacent normal lung tissues were compared using real-time reverse transcription polymerase chain reaction. Although BALB/c nude mice inoculated with parental PC14 cells had few metastases, almost all mice inoculated with PC14HM cells developed metastases in multiple organs, including the lung, bone and adrenal gland, the same progression seen in human lung cancer. cDNA microarray analysis revealed that 981 genes were differentially (more than 3-fold) expressed between the two cell lines. Functional classification revealed that many of those genes were associated with cell growth, cell communication, development and transcription. Expression of three upregulated genes (HRB-2, HS3ST3A1 and RAB7) was higher in human cancer tissue compared to normal lung tissue, while expression of EDG1, which was downregulated, was lower in the cancer tissue compared to the normal lung. These results suggest that the newly established PC14HM cell line may provide a mouse model of widespread metastasis of lung cancer. This model system may provide insights into the key genetic determinants of widespread metastasis of lung cancer.

Superior vena cava rupture caused during balloon dilation for treatment of SVC syndrome due to repetitive catheter ablation : A case report

A 29-year-old woman with an implanted AAI mode permanent pacemaker, who had undergone catheter ablation for inappropriate sinus tachycardia 4 times, experienced complications of superior vena cava (SVC) syndrome. Severe stenosis of the SVC wall was observed in computed tomograms. During balloon dilation for the treatment of SVC syndrome, the SVC was ruptured, resulting in cardiac tamponade. An emergency operation was performed using percutaneous cardiopulmonary support (PCPS). A longitudinal tear 1 cm in length was identified at the junction of the right atrium and the SVC, requiring a patch plasty using an autologous pericardium 2.5 cm x 3 cm in size. SVC rupture is a complication to be completely avoided when we perform balloon dilation for the treatment of SVC syndrome. Therefore, the indication of balloon dilation for the treatment of SVC syndrome requires critical examination and attention.

Is epidural analgesia necessary after video-assisted thoracoscopic lobectomy?

Most studies have shown that thoracic epidural analgesia reduces postoperative pain, but it carries potential risks. Recently, video-assisted thoracoscopic surgery has become an established technique that causes minimal postoperative pain. This report shows that thoracic epidural analgesia is not always necessary after video-assisted thoracoscopic lobectomy. From January to December 2007, 30 consecutive patients who underwent video-assisted thoracoscopic lobectomy were examined retrospectively. We analyzed the necessity for routine thoracic epidural analgesia. The continuous subcutaneous analgesia catheter for morphine (2 mg in 48 h) was removed from 15 patients on postoperative day 1, and from the other 15 on day 2. We administered loxoprofen sodium hydrate, diclofenac sodium suppository, pentazocine hydrochloride, and mexiletine hydrochloride for postoperative analgesia, as needed. The mean pain score was no more than 1.0. The maximum score was 3.0 on day 0, and 2.0 on day 14; subsequently, no pain score exceeded 2.0. The postoperative hospital stay was 8.7 ± 0.8 days. All patients made uneventful postoperative recoveries. There is no need for thoracic epidural analgesia after every video-assisted thoracoscopic lobectomy because our patients recovered with no serious complication. Less invasive surgical approaches should require simpler postoperative pain management.

A novel technique for closing a tracheocutaneous fistula using a hinged skin flap

We present the case of a 73-year-old man with successful closure of a persistent tracheocutaneous tissue defect that resulted from poor wound healing after a temporary tracheostomy was performed during treatment for drug-induced anaphylactic shock. We repaired the tracheal defect using a cutaneous flap with its cutaneous surface positioned to cover the tracheal lumen. The advantage of our method is that it minimizes the suturing required and results in fewer problems with anastomotic insufficiency. This is a simple, rapid method for treating tracheocutaneous fistulas.

Association of variations in HLA class II and other loci with susceptibility to EGFR -mutated lung adenocarcinoma

Lung adenocarcinoma driven by somatic EGFR mutations is more prevalent in East Asians (30–50%) than in European/Americans (10–20%). Here we investigate genetic factors underlying the risk of this disease by conducting a genome-wide association study, followed by two validation studies, in 3,173 Japanese patients with EGFR mutation-positive lung adenocarcinoma and 15,158 controls. Four loci, 5p15.33 (TERT), 6p21.3 (BTNL2), 3q28 (TP63) and 17q24.2 (BPTF), previously shown to be strongly associated with overall lung adenocarcinoma risk in East Asians, were re-discovered as loci associated with a higher susceptibility to EGFR mutation-positive lung adenocarcinoma. In addition, two additional loci, HLA class II at 6p21.32 (rs2179920; P =5.1 × 10−17, per-allele OR=1.36) and 6p21.1 (FOXP4) (rs2495239; P=3.9 × 10−9, per-allele OR=1.19) were newly identified as loci associated with EGFR mutation-positive lung adenocarcinoma. This study indicates that multiple genetic factors underlie the risk of lung adenocarcinomas with EGFR mutations.

Rupture of the diaphragm and pericardium with cardiac herniation after blunt chest trauma.

A 61-year-old man was transferred to our institution because of blunt chest trauma after accidentally falling. A chest roentgenogram (CXR) and computed tomography (CT) revealed bilateral hemopneumothorax and fractures of multiple left ribs, the pelvis, and the left femur. On the second day in hospital, the patient suddenly complained of dyspnea. Emergency CXR and CT revealed elevation of the left diaphragm, suggestive of a traumatic diaphragmatic hernia; emergency surgery was performed. We confirmed rupture of the diaphragm and pericardium with cardiac herniation: the pleural pericardium and diaphragm were torn individually, and the heart and abdominal organs had herniated into the pleural cavity. They were repaired, and there were no cardiopulmonary complications during or after the operation. Pericardiodiaphragmatic rupture with cardiac herniation after multiple blunt traumas is rare. We describe the successful treatment of a diaphragmatic and pericardial rupture with cardiac herniation, with special reference to pericardial injuries.

Effect of landiolol hydrochloride, an ultra‐short‐acting beta 1‐selective blocker, on supraventricular tachycardia, atrial fibrillation and flutter after pulmonary resection

What is known and objective:  Supraventricular tachycardia is a common complication after pulmonary resection. The objective of this study was to investigate the efficacy of landiolol hydrochloride, an ultra‐short‐acting β1‐blocker, in patients with post‐operative supraventricular tachycardia after pulmonary resection.

A new application of a wound retractor for chest wall surgery.

Use of a wound retraction (WR) is useful for lung resection by video-assisted thoracic surgery via a mini-thoracotomy. We have employed a WR for chest wall surgery involving surgical rib fixation in a patient with rib fractures, and obtained successful results in terms of a good surgical view and lack of postoperative wound infection. On the basis of our experience, we consider that a WR is useful even for chest wall surgery.

Serial Chest Films Are Needed After a Diagnosis of Pneumopericardium Because of Risk of Cardiac Herniation

A 76-year-old man was transferred to our institution with blunt chest trauma after falling off a roof. Chest computed tomography (CT) revealed left pneumothorax and pneumopericardium but no displacement of the heart into the hemithorax. These findings suggested traumatic pericardial rupture without cardiac herniation. After chest drainage, a follow-up CT scan demonstrated no pericardial or pleural air. At thoracotomy, we observed that the pericardium was torn and that the heart was exposed. The tear was repaired with direct sutures. This case report highlights the importance of reviewing the initial CT scan.