Predictive factors inhibiting recovery of the respiratory function after anatomical pulmonary resection.

PURPOSE: Some patients have worse actual observed postoperative (apo) respiratory function values than predicted postoperative (ppo) values. The present study therefore clarified the predictive factors that hinder the recovery of the postoperative respiratory function. METHODS: This study enrolled 255 patients who underwent anatomical pulmonary resection for lung cancer. A pulmonary function test (PFT) was carried out before surgery and at one, three, and six months after surgery. In each surgical procedures, the forced expiratory volume in 1 s (FEV1) ratio was calculated as the apo value divided by the ppo value. In addition, we investigated the predictive factors that inhibited postoperative respiratory function improvement in patients with an FEV1 ratio < 1.0 at 6 months after surgery. RESULTS: The FEV1 ratio gradually improved over time in all surgical procedures. However, 49 of 196 patients who underwent a PFT at 6 months after surgery had an FEV1 ratio < 1.0. In a multivariate analysis, right side, upper lobe, segmentectomy and pleurodesis for prolonged air leakage were independent significant predictors of a decreased FEV1 ratio (p = 0.003, 0.006, 0.001, and 0.009, respectively). CONCLUSION: Pleurodesis was the only controllable factor that might help preserve the postoperative respiratory function. Thus, the intraoperative management of air leakage is important.

Penetrating Aortic Injury due to Broken Ribs and Preventive Measures.

We herein report two cases of patients that underwent prophylactic operations to prevent aortic injuries in association with fractured ribs. Penetrating aortic injuries induced by fractured ribs remain fatal. Prophylactic operations appear effective. However, the indication for such operations should be clarified further in the future.

Congenital Pulmonary Airway Malformation in Children: Advantages of an Additional Trocar in the Lower Thorax for Pulmonary Lobectomy.

Aim: To present the use of an additional trocar (AT) in the lower thorax during thoracoscopic pulmonary lobectomy (TPL) in children with congenital pulmonary airway malformation. Methods: For a lower lobe TPL (LL), an AT is inserted in the 10th intercostal space (IS) in the posterior axillary line after trocars for a 5-mm 30° scope, and the surgeon's left and right hands are inserted conventionally in the 6th, 4th, and 8th IS in the anterior axillary line, respectively. For an upper lobe TPL (UL), the AT is inserted in the 9th IS, and trocars are inserted in the 5th, 3rd, and 7th IS, respectively. By switching between trocars (6th↔8th for the scope, 4th↔6th for the left hand, and 8th↔10th for the right hand during LL and 5th↔7th, 3rd↔5th, and 7th↔9th during UL, respectively), vital anatomic landmarks (pulmonary veins, bronchi, and feeding arteries) can be viewed posteriorly. The value of AT was assessed from blood loss, operative time, duration of chest tube insertion, requirement for post-operative analgesia, and incidence of perioperative complications. Results: On comparing AT+ (n = 28) and AT- (n = 27), mean intraoperative blood loss (5.6 vs. 13.0 ml), operative time (3.9 vs. 5.1 h), and duration of chest tube insertion (2.2 vs. 3.4 days) were significantly decreased with AT (p < 0.05, respectively). Differences in post-operative analgesia were not significant. There were three complications requiring conversion to open/mini-thoracotomy: AT- (n = 2; bleeding), AT+: (n = 1; erroneous stapling). Conclusions: An AT and switching facilitated posterior dissection during TPL in children with congenital pulmonary airway malformation enhancing safety and efficiency.

Intraoperative complications and troubles in robot-assisted anatomical pulmonary resection.

OBJECTIVE: Regarding intraoperative complications and troubles during robot-assisted thoracic surgery, few data are available especially in Japan. This study was aimed to elucidate intraoperative complications and troubles in robotic anatomical lung resection, and to present managements and outcomes of those. METHODS: This was a retrospective singe-institutional study. The first 192 consecutive patients who underwent robot-assisted anatomical lung resection between January 2017 and August 2019 were evaluated. We examined the frequency, management and outcomes of intraoperative complications and troubles. RESULTS: Of the 192 eligible patients who underwent robotic anatomical lung resection, lobectomy was performed for 156 (81.2%), and segmentectomy for 36 (18.8%). Three (1.5%) required conversion to open thoracotomy. Of these, bleeding from the pulmonary artery was the cause in two patients (1.0%) and inflammatory adhesion of hilar lymph nodes in 1 (0.5%). Other intraoperative complications and troubles included bronchial injuries in 3 patients (1.5%), lung injury by assistant in one patient (0.5%) and horizontal movement limitation of da Vinci arm in one patient (0.5%). Regarding bronchial injuries, two of three were stump injuries related to stapling, the remaining was to dissection of the bronchial tissues. All bronchial repairs were completed without conversion, and postoperative complications related to bronchial injury were not observed. The 30-day and 90-day mortality rates were both 0%. CONCLUSIONS: The frequency of intraoperative complications and troubles in robot-assisted thoracic surgery was low in our first series. All conversions were related to bleeding and impending bleeding, and no conversion was required for bronchial injury.

Does fissure status affect the outcome of thoracoscopic pulmonary lobectomy?

PURPOSE: We studied fissure status and devices used to divide lung parenchyma during thoracoscopic pulmonary lobectomy (TPL). METHODS: 52 consecutive TPL indicated for congenital pulmonary airway malformation or interlobar pulmonary sequestration performed between 2009 and 2019 were reviewed prospectively to compare patients with absent fissure and no visible interlobar pulmonary artery (IPA) treated by stapling (group A; n = 10), incomplete fissure with partially visible IPA treated with an Enseal® or LigaSure™ device (group I; n = 17), and complete fissure with fully visible IPA treated by electrocautery (group C; n = 25). RESULTS: Patient demographics were similar. Mean age at TPL was 2.82 years (range 0.03-9.81). Mean duration of follow-up was 4.77 years (range 0.33-10.19). Operative time and duration of chest tube insertion were similar (p = NS). Intraoperative blood loss was significantly lower in group C compared with group I (p = 0.028). Complications were minor bronchial artery hemorrhage during anterior-to-posterior bronchial dissection (group A: n = 1; group I: n = 1), problematic single lung ventilation (group I: n = 1), and persistent postoperative air leak (group I: n = 1). CONCLUSION: While fissure status does not appear to affect the outcome of TPL in children, the choice of device for dividing lung parenchyma relies specifically on fissure status.

Thoracoscopic Pulmonary Lobectomy for Densely Fused Pulmonary Lobes in Children with Congenital Pulmonary Airway Malformation: Technical Tips.

AIM: Thoracoscopic pulmonary lobectomy (TPL) is extremely challenging in cases where severe incomplete fissure causes densely fused pulmonary lobes (DFPL) since pulmonary arteries (PAs) are buried and completely concealed by DFPL. We describe TPL for DFPL including a technical tip to prevent pitfalls. MATERIALS AND METHODS: Four congenital pulmonary airway malformation (CPAM) and DFPL (left-upper: 2, left-lower: 1, right-middle: 1) were treated. During TPL, DFPL prevent interlobar PAs from being identified and searching for them only promotes bleeding and air leakage, serious pitfalls that affect the safety and success of TPL. Our tip is to ligate and divide the pulmonary veins (PVs) at the pulmonary hilum and the hilar PA supplying the CPAM lobe to expose the bronchus of the lobe, which is then ligated and divided. The main PA supplying the lobe running underneath the DFPL is exposed and visible from the pulmonary hilum allowing the PA supplying the lobe to be ligated and divided safely. A line demarcating the fused fissure becomes apparent, and an endoscopic stapler or EnSeal® device can be used to divide the DFPL along the line taking great care not to injure the main PA or interlobar PAs. RESULTS: There were no intra-/postoperative complications in any case. All patients performed well without respiratory tract-related symptoms after a mean follow-up of 4.6 years. CONCLUSIONS: TPL for DFPL in children with CPAM can be performed safely and successfully as a virtually bloodless procedure and without incidence of air leakage by ligating and dividing the PA after dividing the PVs and bronchus to the lobe.

Case report of cardiac herniation after sleeve pneumonectomy with superior vena cava reconstruction.

Cardiac herniation is a complication that occurs after intrapericardial pneumonectomy. It is life-threatening unless promptly diagnosed and surgery performed. We report a case of cardiac herniation after right intrapericardial pneumonectomy following radiotherapy for lung cancer. The patient developed cardiac herniation with sudden hypotension following a switch to the spine position. An immediate switch to the lateral decubitus position improved the cardiocirculatory dynamics, and surgical patch closure was performed. The circulation dynamics was unstable for several hours after surgery with elevated enzyme levels, which improved 2 days later. Immediate thoracotomy before irreversible myocardial damage resulted in a successful outcome. The risk of cardiac herniation should always be considered after intrapericardial pneumonectomy.

Distinct Clinicopathologic Characteristics and Prognosis Based on the Presence of Ground Glass Opacity Component in Clinical Stage IA Lung Adenocarcinoma.

INTRODUCTION: We evaluated differences in the clinicopathologic characteristics and prognosis based on the presence of ground glass opacity (GGO) components in small-sized lung adenocarcinoma. METHODS: We retrospectively investigated 634 lung adenocarcinomas classed as c-stage IA in the eighth edition TNM classification. Staging was defined according to the solid component size measured by thin-section computed tomography. All tumors were grouped into either a GGO or solid group, based on the presence of a GGO component. RESULTS: Of the cases, 215 (34%) were classed as c-stage IA1 (T1mi: 88, T1a-GGO: 102, T1a-solid: 25), 255 (40%) as c-stage IA2 (T1b-GGO: 122, T1b-solid: 133), and 164 (26%) as c-stage IA3 (T1c-GGO: 44, T1c-solid: 120). Among the 546 c-stage IA cases excluding the T1mi lesions, Cox regression analysis revealed that presence of GGO was an independently significant prognosticator (p = 0.024). The result was validated in 494 c-stage IA lung adenocarcinomas with a nonpredominant GGO component, showing the presence of GGO as a significant prognosticator (p = 0.048). When we evaluated the prognostic impact of GGO presence in each clinical stage, the 5-year overall survival (OS) was significantly different between the GGO and solid groups (IA1: 97.8% versus 86.6%, p = 0.026; IA2: 89.3% versus 75.2%, p = 0.007; IA3: 88.5% versus 62.3%, p = 0.003). Furthermore, the 5-year overall survival b was distinct in parallel similar pathologic findings when comparing a lepidic versus an invasive component (IA1: 97.9% versus 85.6%, p = 0.031; IA2: 86.1% versus 69.4%, p = 0.007; IA3: 77.5% versus 55.8%, p < 0.001). CONCLUSIONS: Clinicopathologic and oncologic outcomes were disparate based on the presence of a GGO component in the eighth edition TNM classification of c-stage IA lung adenocarcinoma.

Limb-Shaking Transient Ischemic Attack Induced by Middle Cerebral Artery Dissection after Lung Surgery.

We report a case of limb-shaking transient ischemic attack (TIA) caused by a dissection of the middle cerebral artery (MCA) following lung surgery under general anesthesia. An 81-year-old male patient who underwent lobectomy for lung cancer suddenly developed transient shaking movements of the neck and the left upper distal limb on postoperative day 1. On the basis of the double-barrel appearance of the right M1 segment of the MCA, a diagnosis of MCA dissection was made. Physicians should be aware that limb-shaking TIA is sometimes caused by MCA dissection and could be precipitated by any condition, including lung surgery under general anesthesia.

Utility of Objective Chest Tube Management After Pulmonary Resection Using a Digital Drainage System.

BACKGROUND: We sought to evaluate the clinical utility of chest tube management after pulmonary resection based on objective digital monitoring of pleural pressure and digital surveillance for air leaks. METHODS: We prospectively recorded the perioperative data of 308 patients who underwent pulmonary resection between December 2013 and January 2016. We used information from a digital monitoring thoracic drainage system to measure peak air leakage during the first 24 hours after the operation, patterns of air leakage over the first 72 hours, and patterns of pleural pressure changes until the chest tubes were removed. RESULTS: There were 240 patients with lung cancer and 68 patients with other diseases. The operations included 49 wedge resections, 58 segmentectomies, and 201 lobectomies. A postoperative air leak was observed in 61 patients (20%). A prolonged air leak exceeding 20 mL/min lasting 5 days or more was observed in 18 patients (5.8%). Multivariate analysis of various perioperative factors showed forced expiratory volume in 1 second below 70%, patterns of air leakage, defined as exacerbating and remitting or without a trend toward improvement, and peak air leakage of 100 mL/min or more were significant positive predictors of prolonged air leak. Fluctuations in pleural pressure occurred just after the air leakage rate decreased to less than 20 mL/min. CONCLUSIONS: Digital monitoring of peak air leakage and patterns of air leakage were useful for predicting prolonged air leak after pulmonary resection. Information on the disappearance of air leak could be derived from the change in the rate of air leakage and from the increase in fluctuation of pleural pressure.

Forkhead box P3 regulatory T cells coexisting with cancer associated fibroblasts are correlated with a poor outcome in lung adenocarcinoma.

Recently, an association between tumor infiltrating Forkhead box P3 regulatory T cells (Treg ) and an unfavorable prognosis has been clinically shown in some cancers, but the mechanism of Treg induction in the tumor microenvironment remains uncertain. The aims of the present study were to examine the relationship between Treg and patient outcome and to investigate whether Treg induction is influenced by the characteristics of cancer-associated fibroblasts (CAF) in lung adenocarcinoma. The numbers of Treg in both the tumor stroma and the tumor nest were counted in 200 consecutive pathological stage I lung invasive adenocarcinoma specimens. To examine whether the characteristics of CAF influence Treg induction, we selected and cultured CAF from low Treg and high Treg adenocarcinoma. The number of Treg was much higher in the stroma than in the nest (P < 0.01). Patients with high Treg had a significantly poorer prognosis than those with low Treg (overall survival: P = 0.03; recurrence-free survival: P = 0.02; 5-year overall survival: 85.4% vs 93.0%). Compared with the CAF from low Treg adenocarcinoma, culture supernatant of the CAF from high Treg adenocarcinoma induced more Treg (P = 0.01). Also, CAF from high Treg adenocarcinoma expressed significantly higher mRNA levels of transforming growth factor-ß (P = 0.01) and vascular endothelial growth factor (P = 0.01), both of which are involved in Treg induction. Our studies suggest the possibility that CAF expressing immunoregulatory cytokines may induce Treg in the stroma, creating a tumor-promoting microenvironment in lung adenocarcinoma that leads to a poor outcome.

Prognostic impact of CD204-positive macrophages in lung squamous cell carcinoma: possible contribution of Cd204-positive macrophages to the tumor-promoting microenvironment.

INTRODUCTION: Tumor-associated macrophages (TAMs) are recruited into cancer-induced stroma and produce a specific microenvironment for cancer progression. CD204 (+) TAMs are reportedly related to tumor progression and clinical outcome in some tumors. The aim of this study was to clarify the correlation between CD204 (+) TAMs and the clinicopathological features of lung squamous cell carcinoma. METHODS: We investigated the relationships between the numbers of CD204 (+) TAMs and clinicopathological factors, microvessel density, and the numbers of Foxp3 (+) lymphocytes in 208 consecutively resected cases. We also examined the relationships between the numbers of CD204 (+) TAMs and the expression levels of cytokines involved in the migration and differentiation of CD204 (+) TAMs. RESULTS: A high number of CD204 (+) TAMs in the stroma was significantly correlated with an advanced p-stage, T factor, N factor, and the presence of vascular and pleural invasion. A high number of CD204 (+) TAMs in the stroma was also a significant prognostic factor for all p-stages and p-stage I. Moreover, the numbers of CD204 (+) TAMs were correlated with the microvessel density and the numbers of Foxp3 (+) lymphocytes. A high number of CD204 (+) TAMs was strongly correlated with the tissue expression level of monocyte chemoattractant protein-1. CD204 (+) TAMs were shown to be significant independent prognostic factors in a multivariate analysis. CONCLUSIONS: CD204 (+) TAMs were an independent prognostic factor in lung squamous cell carcinoma. CD204 (+) TAMs, along with other tumor-promoting stromal cells such as regulatory T cells and endothelial cells, may create tumor-promoting microenvironments.