[Thoracoscopic Right Lower Lobectomy Safely Performed after the Identification of Anomalous Middle Pulmonary Vein by Preoperative Three-dimensional Computed Tomography Angiography: Report of a Case].

A complete thoracoscopic right lower lobectomy was successfully performed for a 74-year-old woman with an anomalous right middle lobe pulmonary vein, forming a common trunk of V4+5 and V6 . Preoperative three-dimensional computed tomography was useful to identify the vascular anomaly and contributed to perform safe surgery under the thoracoscopy.

Surgical Outcome after Sleeve Pneumonectomy for Thoracic Malignancy: A Comparison Between Salvage and Non-salvage.

Objectives: Tumors invading the tracheobronchial angle or carina have long presented a challenge due to the complexity of airway reconstruction and management; thus, few medical centers have developed experience with this type of surgery. In this report, we review our experience with Sleeve Pneumonectomy (SP) and analyze both operative risks and outcomes. Materials and Methods: A retrospective review identified 34 patients who underwent SP: 19 underwent salvage SP and 15 underwent non-salvage SP. Salvage surgery was performed for recurrent lung cancer after chemoradiotherapy and could be considered if there were no other therapeutic options or in the presence of urgent symptoms, such as hemoptysis, obstructive pneumonia, superior vena cava syndrome, or tracheoesophageal fistula.The perioperative morbidity and oncological outcomes of salvage and non-salvage SP were analyzed. Results: Most cases were of lung cancer, whereas salvage SP included one case of SVC syndrome due to metastasis of colon cancer and one case of hemoptysis due to metastasis of leiomyosarcoma. Complications occurred in 47% of the non-salvage SP cases and 53% of the salvage SP cases. The 30-day mortality rates were zero in the non-salvage cases and 11% in the salvage cases. The 90-day mortality rates were 20% and 16% in the non-salvage and salvage groups, respectively. Conclusions: The salvage of SP after chemoradiotherapy or in the presence of urgent symptoms is feasible. We believe that it can be an option that improves quality of life (QOL) through longer desease-free survival (DFS) and alleviation of symptoms, rather than waiting for tumor growth progression and exacerbation of symptoms.

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.

Robot-assisted Intercostal Nerve Harvesting: A Technical Note about the First Case in Japan.

Recently, surgical robotic systems have been used to perform microsurgery. Surgical robots have certain properties that make them well suited to microsurgery; for example, they possess 3-dimensional vision, which can be magnified up to 25 times; their movements are up to 5 times more precise than those of surgeons; they possess 7 degrees of wrist articulation; they do not suffer from physiologic tremors; and they can achieve ergonomic surgical positions. The purpose of this study was to report the feasibility of robot-assisted intercostal nerve harvesting in a clinical case. A healthy 57-year-old man suffered a left plexus injury. On diagnosis of clavicular brachial plexus injury, the intercostal nerve transfer to the muscular cutaneous nerve to restore elbow flexion was performed with Da Vinci Xi robot. The harvesting of intercostal nerves using the conventional open approach involves significant surgical exposure, which can lead to perioperative complications. Robot-assisted intercostal nerve harvesting might reduce postoperative pain, shorten patients' hospital stays, lower complication rates, and produce better quality-of-life outcomes. There are many issues to be solved when performing robotic surgery on peripheral nerves in Japan. However, robot-assisted intercostal nerve harvesting was a feasible surgical procedure, and patient satisfaction was high.

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.

The role of virtual-assisted lung mapping in the resection of ground glass nodules.

BACKGROUND: Virtual-assisted lung mapping (VAL-MAP), a bronchoscopic multi-spot dye-marking technique, was tested for its ability to resect ground glass nodules (GGNs) in sublobar lung resections. METHODS: All patients were prospectively registered in the multi-institutional lung mapping (MIL-MAP) study using VAL-MAP. The data were retrospectively analyzed, focusing on GGNs. GGN characteristics, pathological findings, operation type, and the surgical contribution of VAL-MAP were evaluated. RESULTS: The 370 GGNs in 299 patients included 257 pure and 113 mixed GGNs. There were 146 wedge resections (43.6%), 99 simple segmentectomies (29.6%), and 60 complex segmentectomies (18.0%). The largest number of marks were used in complex segmentectomy (4.05±0.74), followed by simple segmentectomy (3.35±0.97) and wedge resection (2.96±0.80). The overall successful resection rate was 98.6%. Multiple [2-5] GGNs were concurrently targeted by VAL-MAP in 53 patients (17.7%) with 123 GGNs. Two concurrent resections were conducted in 36 patients (12.1%), most commonly wedge resection and segmentectomies (21 patients). Among 190 sub-centimeter GGNs, 24 out of 51 GGNs ≤5 mm in diameter (47.1%) and 113 of 139 GGNs >5 mm in diameter (81.3%) were primary lung cancer (P<0.0001). Regarding the contribution of VAL-MAP to successful resection, wedge resection and pure GGNs were graded higher than both other resection types and mixed GGNs. CONCLUSIONS: VAL-MAP enabled thoracoscopic limited resection of GGNs. Its multiple marks facilitated resections of multi-centric GGNs. Resected suspicious GGNs >5 mm in diameter are likely to be lung cancer. VAL-MAP may impact decision-making regarding the indications and type of surgery for suspicious small GGNs.

Comparison of digital and traditional thoracic drainage systems for postoperative chest tube management after pulmonary resection: A prospective randomized trial.

OBJECTIVE: The objective of this study was to evaluate whether a digital thoracic drainage system (group D) is clinically useful compared with a traditional thoracic drainage system (group T) in chest tube management following anatomic lung resection. METHODS: Patients scheduled to undergo segmentectomy or lobectomy were prospectively randomized before surgery to group D or T. A stratification randomization was performed according to the following air leak risk factors: age, sex, smoking status, and presence of emphysema and/or chronic obstructive pulmonary disease. The primary end point was the duration of chest tube placement. RESULTS: No statistically significant differences were found between groups D (n = 135) and T (n = 164) with regard to the duration of chest tube placement (median, 2.0 vs 3.0 days; P = .149), duration of hospitalization (median, 6.0 vs 7.0 days; P = .548), or frequency of postoperative adverse events (25.1% vs 20.7%; P = .361). In subgroup analyses of the 64 patients with postoperative air leak (20 in group D and 44 in group T), the duration of chest tube placement (median, 4.5 vs 4.0 days; P = .225) and duration of postoperative air leak (median, 3.0 vs 3.0 days; P = .226) were not significantly different between subgroups. CONCLUSIONS: The use of a digital thoracic drainage system did not shorten the duration of chest tube placement in comparison to a traditional thoracic drainage system after anatomic lung resection.

Arterial Thoracic Outlet Syndrome and Cerebellar Infarction Following a Stress Fracture of the First Rib and Extensive Callus Formation: A Case Report.

CASE: Stress fractures of the first rib rarely have been reported in association with sports activities. We report a case of a cerebellar infarction that possibly was associated with arterial thoracic outlet syndrome (aTOS) that developed as a result of extensive callus formation in a young baseball player with a stress fracture of the first rib. CONCLUSION: According to the literature, almost all cases of stress fracture in the first rib have a relatively good prognosis, and there are only a few reports of TOS occurring as a rare late complication. To our knowledge, there have been no prior reports of cerebellar infarction associated with aTOS following a stress fracture of the first rib.

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.

Correlation of EGFR or KRAS mutation status with 18F-FDG uptake on PET-CT scan in lung adenocarcinoma.

BACKGROUND: 18F-fluoro-2-deoxy-glucose (18F-FDG) positron emission tomography (PET) is a functional imaging modality based on glucose metabolism. The correlation between EGFR or KRAS mutation status and the standardized uptake value (SUV) of 18F-FDG PET scanning has not been fully elucidated. METHODS: Correlations between EGFR or KRAS mutation status and clinicopathological factors including SUVmax were statistically analyzed in 734 surgically resected lung adenocarcinoma patients. Molecular causal relationships between EGFR or KRAS mutation status and glucose metabolism were then elucidated in 62 lung adenocarcinomas using cap analysis of gene expression (CAGE), a method to determine and quantify the transcription initiation activities of mRNA across the genome. RESULTS: EGFR and KRAS mutations were detected in 334 (46%) and 83 (11%) of the 734 lung adenocarcinomas, respectively. The remaining 317 (43%) patients had wild-type tumors for both genes. EGFR mutations were more frequent in tumors with lower SUVmax. In contrast, no relationship was noted between KRAS mutation status and SUVmax. CAGE revealed that 4 genes associated with glucose metabolism (GPI, G6PD, PKM2, and GAPDH) and 5 associated with the cell cycle (ANLN, PTTG1, CIT, KPNA2, and CDC25A) were positively correlated with SUVmax, although expression levels were lower in EGFR-mutated than in wild-type tumors. No similar relationships were noted with KRAS mutations. CONCLUSIONS: EGFR-mutated adenocarcinomas are biologically indolent with potentially lower levels of glucose metabolism than wild-type tumors. Several genes associated with glucose metabolism and the cell cycle were specifically down-regulated in EGFR-mutated adenocarcinomas.

Safety and reproducibility of virtual-assisted lung mapping: a multicentre study in Japan.

OBJECTIVES: Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multispot dye-marking technique using virtual images. The purpose of this study was to evaluate the safety, efficacy and reproducibility of VAL-MAP among multiple centres. METHODS: Selection criteria included patients with pulmonary lesions anticipated to be difficult to identify at thoracoscopy and/or those undergoing sub-lobar lung resections requiring careful determination of resection margins. Data were collected prospectively and, if needed, compared between the centre that originally developed VAL-MAP and 16 other centres. RESULTS: Five hundred patients underwent VAL-MAP with 1781 markings (3.6 ± 1.2 marks/patient). Complications associated with VAL-MAP necessitating additional management occurred in four patients (0.8%) including pneumonia, fever and temporary exacerbation of pre-existing cerebral ischaemia. Minor complications included pneumothorax (3.6%), pneumomediastinum (1.2%) and alveolar haemorrhage (1.2%), with similar incidences between the original centre and other centres. Marks were identifiable during operation in approximately 90%, whereas the successful resection rate was approximately 99% in both groups, partly due to the mutually complementary marks. The contribution of VAL-MAP to surgical success was highly rated by surgeons resecting pure ground glass nodules ( P < 0.0001), tumours ≤ 5 mm ( P = 0.0016), and performing complex segmentectomy and wedge resection ( P = 0.0072). CONCLUSIONS: VAL-MAP was found to be safe and reproducible among multiple centres with variable settings. Patients with pure ground glass nodules, small tumours and resections beyond conventional anatomical boundaries are considered the best candidates for VAL-MAP. CLINICAL TRIAL REGISTRATION NUMBER: UMIN 000008031. University Hospital Medical Information Network Clinical Trial Registry ( http://www.umin.ac.jp/ctr/ ).

Pulmonary lobectomy techniques in infants and children.

Thoracoscopic pulmonary lobectomy (TPL) techniques in infants and children are presented practically with concise descriptions and numerous illustrations. TPL is the treatment of choice for congenital pulmonary airway malformation and intralobar pulmonary sequestration, both now commonly diagnosed prenatally. Timing of surgery is somewhat controversial in asymptomatic cases with small isolated lesions. Incomplete fissures and history of chest infections are most problematic. Thorough understanding of anatomic relations preoperatively is vital for successful outcome and thin-slice computed tomography with 3D reconstruction of vessels is valuable. Judicious placement of trocars and switching instruments between trocars improves visualization and safety. Specific techniques for all commonly performed TPL are included.

Body Mass Index as a Prognostic Factor in Resected Lung Cancer: Obesity or Underweight, Which Is the Risk Factor?

BACKGROUND: In general, obesity is thought to be associated with increased surgical mortality and morbidity. On the other hand, low body mass index (BMI) has recently been reported as a poor prognostic factor for surgical candidates. This study investigated the effect of BMI on lung surgery. METHODS: A retrospective study was conducted on 1,518 consecutive patients who had malignant pulmonary tumors resected between February 2008 and March 2013. BMI was used to classify patients according to the World Health Organization definition: BMI < 18.5: underweight (UW); BMI 18.5 to <25: normal weight (NW); BMI 25 to <30: overweight (OW); and BMI ≥ 30: obese (OB). We defined surgical resection-related mortality as any patient who died within 90 days after resection or while in the hospital. We analyzed morbidity and surgical resection-related mortality, and logistic regression analysis was used to identify predictors for surgical resection-related mortality. RESULTS: Among the four groups, the incidence of cerebrovascular complications was 1.5% in UW, 0.4% in NW, 0% in OW, and 0% in OB, and that of pulmonary complications was 13.1% in UW, 8.4% in NW, 7.3% in OW, and 7.6% in OB. Surgical resection-related mortality was 2.9% in UW, 0.6% in NW, 1.7% in OW, and 0% in OB. Multivariate analysis revealed underweight, diffusing capacity of the lung for carbon monoxide, and male sex as the significant predictors. CONCLUSIONS: In this study, low BMI was an independent risk factor for mortality, and the incidence of cerebrovascular and pulmonary complications tended to be higher in patients with low BMI than in obese patients. Underweight patients should be closely monitored following pulmonary resection.

Video-assisted thoracoscopic lobectomy vs. conventional lobectomy via open thoracotomy in patients with clinical stage IA non-small cell lung carcinoma.

The aim of this study was to evaluate our personal experience with video-assisted thoracoscopic lobectomy and compare survival between this procedure and conventional lobectomy via open thoracotomy in patients with clinical stage IA non-small cell lung carcinoma. Between May 1997 and December 2004, 140 patients with clinical stage IA non-small cell lung carcinoma had either VATS lobectomy (VATS group, 84 patients) or standard lobectomy via open thoracotomy (open group, 56 patients) performed in our hospital. We compared overall survival, disease-free survival and recurrence between the two groups. The overall survival rate five years after surgery was 72% in the open group and 82% in the VATS group. There were no significant differences in the overall survival rate between the two groups. The disease-free survival rate five years after surgery was 68% in the open group and 80% in the VATS group. There were no significant differences in the disease-free survival rate between the two groups. Five patients in the open group developed distant recurrence, whereas one patient developed regional recurrence. In the VATS group six patients developed distant recurrence, whereas one patient developed regional recurrence. We consider VATS lobectomy to be one of the therapeutic options in patients with clinical stage IA non-small cell lung carcinoma.