Yoshihiko Kurimoto

Is video-assisted thoracoscopic surgery a feasible approach for clinical N0 and postoperatively pathological N2 non-small cell lung cancer?

OBJECTIVE It remains controversial whether video-assisted thoracoscopic surgery (VATS) major pulmonary resection (VMPR) with systematic node dissection (SND) is a feasible approach for clinical N0 and pathological N2 non-small cell lung cancer (cN0-pN2 NSCLC). We compared the clinical outcome of patients who underwent VMPR with SND for cN0-pN2 NSCLC with the outcome of patients who underwent MPR with SND by thoracotomy. We conducted this study to determine the feasibility of VMPR for cN0 and pN2 NSCLC patients and intraoperative node staging by node sampling. METHODS Between 1997 and 2006, 770 patients underwent MPR with SND for NSCLC, wherein 450 patients had VMPR and 320 were subjected to open thoracotomy. There were 673 clinical N0 patients. Among them, we retrospectively reviewed 69 patients (10.3%) with cN0-pN2 NSCLC of which the greatest tumor dimension ranged from 20 to 50mm. These patients were divided into two groups: 37 patients under group V, who underwent VMPR, and 32 patients under group T, who underwent MPR by thoracotomy, for cN0-pN2 NSCLC. The majority of the patients underwent postoperative chemotherapy. RESULTS There were no differences between the two groups regarding preoperative data or the number of nodes dissected. The rate of nodal metastasis (number of metastatic nodes/number of dissected nodes) was similar between the two groups (group V vs group T, 0.24 vs 0.24 in total nodes dissected, 0.24 vs 0.23 in mediastinal nodes dissected). The 3-year and 5-year recurrence-free survivals were similar (60.9% vs 49.6% and 60.9% vs 49.6%), as well. Most of the pattern of recurrence was due to remote metastasis. In like manner, the 3-year and 5-year survivals were similar (67.6% vs 57.7% and 45.4% vs 41.1%). CONCLUSIONS This study demonstrates that VMPR with SND is a feasible surgical therapy for cN0-pN2 NSCLC without loss of curability. It is unnecessary to convert the VATS approach to thoracotomy in order to do SND even if pN2 disease is revealed during VMPR.

Hybrid treatment for aortic arch and proximal descending thoracic aneurysm: experience with stent grafting for second-stage elephant trunk repair

BACKGROUND Aortic aneurysm affecting the arch and proximal descending thoracic aorta may require a two-stage repair, which includes proximal elephant trunk graft placement and completion of descending thoracic aortic repair. The combination of open surgery and endovascular grafting may improve the morbidity and mortality of the patient population at risk. METHODS Between February 2001 and March 2007, 258 patients underwent thoracic aortic endovascular grafting at our institution, wherein 31 patients underwent a hybrid approach involving proximal arch repair and elephant trunk graft replacement, and endovascular completion procedures. All patients, who underwent combined endovascular and open procedures in the management of the aortic arch and proximal descending thoracic aortic aneurysms, were reviewed and analysed retrospectively. RESULTS The interval between the first and second stage ranged from 0 to 14 months with a mean interval of 3.1 months. Follow-up ranged from 0 to 70 months with a mean of 31 months. Technical success was achieved in all patients. The 1, 12, 36 and 60-month mortality rates were 6.4%, 16.5%, 26.7% and 26.7%, respectively. Caudal migration of the endograft occurred in three patients, who underwent conversion to open surgery. Two cases of paraparesis but no paraplegias or strokes were recorded. CONCLUSIONS Staged procedures using endovascular grafting in the treatment of the arch and proximal descending thoracic aneurysm may have the potential to reduce morbidity and mortality rates. Although long-term results are still pending, this early experience demonstrates the safety and early-term effectiveness of this hybrid approach, which consists both of endovascular and open surgical procedures.

Emergency Endovascular Stent-Grafting for Infected Pseudoaneurysm of Brachial Artery

Abstract.The use of covered stents in an infected field is controversial. It is generally recommended that infected aneurysms be treated using autografts or allografts. We report a case of infected brachial pseudoaneurysms that developed after medical debridement of a methicillinresistant Staphylococcus aureus (MRSA)-infected wound of the right arm and emergency brachial artery bypass-grafting using the saphenous vein, which was successfully treated by endovascular stent-grafting followed by antibiotic administration. The present case suggests that endovascular stent-grafting prevents rupture and occlusion of infected aneurysms and enables the continued administration of antibiotics.

Thoracic Endovascular Aortic Repair for Challenging Aortic Arch Diseases Using Fenestrated Stent Grafts From Zone 0

BACKGROUND Although previous reports have described the repair of distal aortic arch aneurysms through debranching and chimney techniques, these methods invariably involve surgical management of the carotid artery. We report clinical results of thoracic endovascular aortic repair (TEVAR) using fenestrated stent grafts in the treatment of aortic arch aneurysms located less than 15 mm from the left common carotid artery. METHODS A semi-custom-made fenestrated stent graft designed to fit aortic arch tortuosity and preserve blood flow at least into the brachiocephalic and left common carotid arteries was placed from zone 0. RESULTS From 2007 through 2013, TEVAR from zone 0 was performed on 37 high-risk patients for open surgery (mean age 78.2 years). The mean length between the left common carotid artery and aortic aneurysm was 11.1 mm (range, 5 to 15 mm). The left subclavian artery was preserved for 26 patients (70.3%) through surgical reconstruction (n = 19) and graft fenestration (n = 7). The early mortality rate was 0%. Postoperative strokes and spinal cord ischemia occurred in 2 (5.4%) and 3 (8.1%) patients, respectively. Although type I endoleaks at discharge were noted in 12 (32.4%) patients, aneurysm enlargement was noted during follow-up in 6 (16.2%). Four patients (10.8%) underwent secondary interventions consisting of 3 coil embolization procedures; 2 re-TEVARs and 1 open conversion. There were no aorta-related late deaths. Survival and aorta-related event-free rates at 2 years were 86.3% and 88.8%, respectively. CONCLUSIONS Thoracic endovascular aortic repair using fenestrated stent graft from zone 0 can be considered as one of therapeutic options for high-risk patients with aortic arch diseases.

An experimental evaluation of the lactate concentration following mesenteric ischemia.

PurposeAlthough a diagnosis of mesenteric necrosis can easily be made, mesenteric ischemia is sometimes overlooked, especially in the acute phase. We experimentally evaluated the time course of the lactate concentration, which may be a possibly useful variable in making a diagnosis of mesenteric ischemia, and determined how an early diagnosis can be made.MethodsThe superior mesenteric artery (SMA) was surgically ligated in an anesthetized pig. Blood tests, including a blood gas analysis, were done using samples from the superior mesenteric vein (SMV), hepatic vein, femoral vein, and artery until 6 h after SMA ligation.ResultsThere were no variables in any samples that showed a significant change within 4 h after SMA ligation except for samples taken from the SMV. All acidosis-related variables had changed significantly within 6 h after ischemia. Among them, the lactate concentration only in the SMV was observed to have increased significantly within one hour after SMA ligation.ConclusionsCurrently available peripheral blood tests, including tests using blood obtained from the hepatic vein, do not enable the detection of mesenteric ischemia within 4 h after onset. In a case in which an exploratory laparotomy is performed, the measurement of the lactate concentration in SMV is thus considered to be a useful supplementary test for making a prompt diagnosis of mesenteric ischemia in an early phase.

Examination of intercostal arteries with transthoracic Doppler sonography.

Objective: There has been no study on the measurement of blood flow of the intercostal artery (ICA) or lumbar artery (LA) with the use of transthoracic Doppler sonography. Here, the method of the ICA depiction and flow measurement were described, and we suggested the clinical usage of this method. Methods: Twelve healthy subjects were examined. The performance of transthoracic Doppler sonography was approached from the back on lateral decubitus position. The intercostal artery was depicted by two‐dimension mode with color flow, and the inner diameter was measured. Peak systolic velocity (PSV), end‐diastolic velocity (EDV), velocity‐time integral (VTI), and heart rate (HR) were measured with pulsed Doppler, and the blood flow was calculated. Results: Bilateral ICAs and LAs from Th4 to L4 were measurable with this method. The PSV of Lt Th9 was the fastest at 43.3 ± 10.1 cm/sec and the PSV of the ICAs gradually decreased as distance from Th9 increased. As for the flow volume, the left Th11 was the greatest at 99.7 mL/min, and the flow volume of the ICA gradually decreased as distance from Th11 increased. The velocity and blood flow of right ICA tended to be lower than the left in the same spinal level. Conclusions: Evaluation technique of serial ICAs and LAs was shown. We think that it may be a clinically useful method in the study of spinal cord circulation in the repair of cases of descending thoracic or thoracoabdominal aortic aneurysm. (Echocardiography 2010;27:17‐20)

Spinal cord protection with selective spinal perfusion during descending thoracic and thoracoabdominal aortic surgery

Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30-40 ml/min for each intercostal artery and was adjusted to keep the proximal circuit pressure at 150-200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesis/paraplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation.

Less-invasive management of left subclavian artery in stent-grafting for distal aortic arch disease

Simple coverage of the left subclavian artery (LSA) in thoracic endovascular aortic repair (TEVAR) is still a controversial procedure. We present our modified strategy dealing with LSA in TEVAR. Hand-made stent grafts were placed more proximal beyond the LSA for 104 patients. In elective 76, preoperative LSA occlusion test was performed on 31 patients, and preoperative computed tomographic angiography (CTA) of the vertebro-basilar artery was performed on the remaining 45. Head vessels were planned to be kept patent using fenestrated stent grafts, if possible. Stent grafts were placed from zone 0 in 23, zone 1 in 39, and zone 2 in 42. The LSA occlusion tests revealed harmful effects, such as loss of consciousness and vertigo in two out of 31 patients (6.5%). Vertebro-basilar arterial CTA revealed possible risks, if LSA covered, in three out of 45 patients (6.7%). Fenestrated stent grafts could successfully preserve 131 head vessels, except for one unintentional occlusion of the left carotid artery (0.75%). There was no LSA-related complication in any of the cases. A combination of preoperative vertebro-basilar arterial CTA and fenestrated stent grafts is useful to avoid possible LSA-related complications in TEVAR.

Minilaparotomy Abdominal Aortic Aneurysm Repair Versus the Retroperitoneal Approach and Standard Open Surgery

PurposeWe evaluated the surgical results of minilaparotomy abdominal aortic aneurysm (AAA) repair in comparison with those of standard open repair and retroperitoneal approach repair.MethodsBetween February 2000 and January 2003, 30 patients with AAA underwent minimal incision laparotomy repair (MINI) through an abdominal incision 7–12 cm long. Their clinical characteristics and in-hospital outcome were then compared with those of patients who had undergone repair of AAA by a standard open technique (OPEN) or retroperitoneal approach technique (RETRO).ResultsThere were significant differences between the MINI, OPEN, and RETRO groups in the time until the patient was able to resume eating (2.4 ± 1.0 vs 4.4 ± 2.4* vs 2.8 ± 1.9 postoperative days [PODs], respectively; *P < 0.05), the time until ambulation outside the room (2.1 ± 0.7 vs 3.5 ± 1.3* vs 2.5 ± 1.9 PODs, respectively; *P < 0.05), and the operation times (188 ± 43* vs 256 ± 77 vs 238 ± 59 min, respectively; *P < 0.05).ConclusionMinilaparotomy repair is a feasible technique, which combines the benefits of a small incision with those of conventional open repair. With the exception of patients with an iliac artery aneurysm extending to the external or internal iliac artery, MINI repair should be considered for the elective treatment of patients with aortic disease.

Endovascular Stent-Graft Repair of Aortobronchial Fistulas

BACKGROUND Endovascular repair of the descending thoracic aorta has recently emerged as a feasible treatment option; however, little is known about its application for aortobronchial fistula (ABF). Experience with endovascular repair of the thoracic aorta and the outcome of patients with ABFs was reviewed to assess whether thoracic endovascular repair is a realistic option. METHODS From February 2001 to May 2011, 386 patients were successfully treated with endoluminal grafts to the distal arch or descending thoracic aorta. Among them, 26 patients with ABF underwent thoracic endovascular repair. These cases were reviewed and analyzed retrospectively. Follow-up was 100% complete (mean, 21 months). RESULTS The subjects included 26 patients (22 males, 85%; 4 females, 15%) with a median age of 71 years. Ten patients (38%) were diagnosed with atherosclerotic aneurysms, 13 (50%) had pseudoaneurysms associated with prior open surgical repair, 1 (4%) had rupture of dissecting aneurysm, and 2 (8%) had mycotic aneurysm. There were 4 (15%) in-hospital mortalities, in which the causes included bleeding owing to recurrence of hemoptysis (n=3, 11%) and multiple organ failure (n=1, 4%). None sustained postoperative stroke or paraplegia. During follow-up, ABFs recurred in 4 patients; of these, endograft explantation occurred in 3 patients and 1 patient required additional open surgery. No hospital mortality resulted among the 4 patients with ABF recurrence. CONCLUSIONS Endovascular management of ABFs appears to be safe and well tolerated with minimal risk, even in surgically high-risk patients. Endovascular stent-graft repair is likely the first choice for ABF presenting as hemoptysis.