Persistent pneumothorax after laparoscopic appendectomy in a patient who had undergone radical esophagectomy 5 years before: possible relationship with vulnerability of the hiatus after esophagectomy: a case report.

Postoperative pneumothorax is a well-known but relatively rare complication after laparoscopic surgery. Herein, we report a case of persistent pneumothorax after laparoscopic appendectomy. A 57-year-old male, with a history of minimally invasive esophagectomy and intrathoracic gastric tube reconstruction 5 years before, underwent a laparoscopic appendectomy. A chest X-ray taken on postoperative Day 1 revealed the development of the right pneumothorax, which took more than 3 days to resolve spontaneously. Although the mechanism of postoperative pneumothorax was unclear, it seemed likely that the air that had replaced carbon dioxide in the peritoneal cavity migrated into the thoracic cavity through the esophageal hiatus, which was not covered by the peritoneum or pleura after surgical resection. The present case, together with our previous similar case, suggests that a history of esophageal cancer surgery per se increases the risk of pneumothorax after laparoscopic surgery, probably regardless of when this was performed.

Persistent bilateral pneumothorax after robotic-assisted inguinal hernia repair: possible relevance to recent esophageal cancer surgery - a case report.

BACKGROUND: Postoperative pneumothorax is a well-known but relatively rare complication after laparoscopic surgery. There has been no report describing pneumothorax that persisted for a week or more after laparoscopic surgery. Herein, we report a case of bilateral pneumothorax after laparoscopic surgery, which appears to have occurred by a different mechanism than previously described. CASE PRESENTATION: A 65-year-old male, with a past history of esophagectomy and retrosternal gastric tube reconstruction 4 months earlier, underwent a robotic-assisted inguinal hernia repair. Postoperative chest x-rays revealed the development of bilateral pneumothorax, which became worse on postoperative day (POD) 1 and took more than 9 days to resolve spontaneously. We assumed that intra-abdominal gas replaced by the air after pneumoperitoneum might have migrated into thoracic cavities through an opened esophageal hiatus or along the retrosternal route. CONCLUSIONS: Laparoscopic surgery after radical esophagectomy may be associated with an increased risk of postoperative pneumothorax.

Associations among preoperative transthoracic echocardiography variables and cerebral near-infrared spectroscopy values at baseline before anesthesia in patients undergoing cardiac surgery: a retrospective observational study.

Cerebral tissue oximetry with near-infrared spectroscopy (NIRS) is used to monitor cerebral oxygenation during cardiac surgery. To date, reduced baseline cerebral NIRS values have been attributed to reduced cerebral blood flow primarily based on a significant positive correlation between left ventricular ejection fraction (LVEF) and baseline rSO2 measured with the INVOS 5100C oximeter. Reportedly, however, rSO2, but not StO2 measured with the FORESIGHT Elite oximeter, correlated with LVEF. We, thus, investigated associations among baseline NIRS values measured with three different oximeters before anesthesia for cardiac surgery and preoperative transthoracic echocardiography (TTE) variables, including LVEF, to examine whether there are inter-device differences in associations among baseline NIRS values and TTE variables. Using Spearman's correlation coefficient, we retrospectively investigated associations among 15 preoperative TTE variables, including LVEF, and baseline NIRS values, including rSO2, StO2, and TOI with the NIRO-200NX oximeter in 1346, 515, and 301 patients, respectively. Only rSO2 (p < 0.00001), but not TOI or StO2 (p > 0.05), positively correlated with LVEF. On the other hand, baseline rSO2, TOI, and StO2 consistently, negatively correlated with the left atrial diameter index (LADI), early diastolic transmitral flow velocity (E), E-to-early diastolic mitral annular velocity ratio (E/e'), estimated right ventricular systolic pressure (eRVP), and inferior vena cava diameter index (IVCDI) (p < 0.0005 to p < 0.00001). Because all of these five TTE variables could be positively associated with right as well as left ventricular filling pressure, our results indicated that reduced baseline NIRS values were consistently associated not with reduced LVEF but with TTE findings indicative of elevated biventricular filling pressure. Our data suggest that regional venous congestion greatly contributes to reduced baseline NIRS values in patients undergoing cardiac surgery.

Introduction of a Multidisciplinary Preoperative Clinic at Juntendo University Hospital - A Retrospective Observational Study Focusing on Effects of Preoperative Interventions on Clinical Outcomes.

Objectives: To investigate the effects of interventions provided by a multidisciplinary team consisting of anesthesiologists, dentists, pharmacists, and nurses at a Preoperative Clinic (POC) on postoperative outcomes. Methods: We retrospectively investigated patients who underwent preoperative evaluation at the POC at Juntendo University Hospital between May and July, 2019. Patients were divided into intervention and non-intervention groups according to whether they received intervention(s) at the POC or not. Postoperative outcomes were compared between the groups, before and after propensity score (PS) matching. Results: We investigated 909 patients who completed POC evaluation and underwent surgery. Patients in the intervention group (n = 455 [50.1%]) received at least one intervention delivered, in the order of higher delivery frequencies, by dentists, pharmacists, nurses, and anesthesiologists. Before PS matching, the intervention group was associated with older age, more frequent cardiovascular comorbidities, and higher ASA-PS grades than the non-intervention group, while neither frequencies nor severities of postoperative complications differed between the groups. These outcomes did not differ between 382 PS-matched pairs with comparable risk factors either. Conclusions: Before PS matching, postoperative outcomes did not differ between the groups, although the intervention group was associated with higher risks. These suggested that POC interventions could have improved postoperative outcomes in the higher-risk intervention group to the same level as in the non-intervention group. However, such potential beneficial effects of interventions could not be proven after PS matching. Further studies are required to elucidate effects of POC interventions on postoperative outcomes.

Effects of the Multidisciplinary Preoperative Clinic on the Incidence of Elective Surgery Cancellation.

To evaluate effects of the multidisciplinary preoperative clinic (POC) consisting of anesthesiologists, dentists, pharmacists, and nurses on elective surgery cancellation, we retrospectively investigated patients who underwent elective non-cardiac, non-obstetric surgeries between October, 2018 and March, 2019 (before the POC establishment: Group 1) and between October, 2019 and March, 2020 (after the POC establishment: Group 2). Among reasons for surgery cancellation allocated into eight categories, three reasons for cancellation (related to consent authorization, medication, and significant comorbidities) were considered preventable. We compared incidences of overall and preventable cancellations of surgeries between 4,198 patients in Group 1 and 4,664 patients in Group 2, who had significantly different clinical backgrounds, including the ASA-PS class. There was no significant difference in the incidence of overall cancellation between Group 1 and Group 2 (4.1% vs. 4.1%, p = 0.96). However, the incidence of preventable cancellation was significantly lower in Group 2 than in Group 1 (0.4% vs. 0.7%, p = 0.045). In addition, the incidence of overall cancellation was significantly lower in 3,741 Group 2 patients visiting the POC than in 5,121 patients not visiting the POC in both Groups (3.2% vs. 4.7%, p < 0.001). Further, in 3,423 pairs of patients with comparable clinical backgrounds created from both Groups using propensity score matching, incidences of overall cancellation (2.2% vs. 3.1%) and preventable cancellation (0.1% vs. 0.6%) were significantly lower in Group 2 than in Group 1 (p = 0.036 and 0.008, respectively). In conclusion, the multidisciplinary POC was effective in reducing elective surgery cancellation.

Disinfection of otorhinolaryngological endoscopes with electrolyzed acid water: A cross-sectional and multicenter study.

Glutaraldehyde, a germicide for reprocessing endoscopes that is important for hygiene in the clinic, might be hazardous to humans. Electrolyzed acid water (EAW) has a broad anti-microbial spectrum and safety profile and might be a glutaraldehyde alternative. We sought to assess EAW disinfection of flexible endoscopes in clinical otorhinolaryngological settings and its in vitro inactivation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and bacteria commonly isolated in otorhinolaryngology. Ninety endoscopes were tested for bacterial contamination before and after endoscope disinfection with EAW. The species and strains of bacteria were studied. The in vitro inactivation of bacteria and SARS-CoV-2 by EAW was investigated to determine the efficacy of endoscope disinfection. More than 20 colony-forming units of bacteria at one or more sampling sites were detected in 75/90 microbiological cultures of samples from clinically used endoscopes (83.3%). The most common genus detected was Staphylococcus followed by Cutibacterium and Corynebacterium at all sites including the ears, noses, and throats. In the in vitro study, more than 107 CFU/mL of all bacterial species examined were reduced to below the detection limit (<10 CFU/mL) within 30 s after contact with EAW. When SARS-CoV-2 was treated with a 99-fold volume of EAW, the initial viral titer (> 105 PFU) was decreased to less than 5 PFU. Effective inactivation of SARS-CoV-2 was also observed with a 19:1 ratio of EAW to the virus. EAW effectively reprocessed flexible endoscopes contributing to infection control in medical institutions in the era of the coronavirus disease 2019 pandemic.

Early postoperative pulmonary complications after minimally invasive esophagectomy in the prone position: incidence and perioperative risk factors from the perspective of anesthetic management.

OBJECTIVES: To investigate the incidence of and the risk factors for early postoperative pulmonary complications (PPC) after minimally invasive esophagectomy (MIE) in the prone position from the perspective of anesthetic management. METHODS: We conducted a historical cohort study of patients who underwent MIE in the prone position between September 2010 and August 2018. PPC was defined as pneumonia, atelectasis, acute respiratory distress syndrome (ARDS), respiratory failure, and pulmonary embolism (Clavien-Dindo Classification Grade II or higher) that occurred within 7 days after MIE. RESULTS: Out of 489 patients, there were 90 patients (18.4%) with PPC: 75 patients with pneumonia, 24 patients with atelectasis, 13 patients with respiratory failure, 6 patients with ARDS, and 2 patients with pulmonary embolism. Twenty-eight patients suffered from 2 or more components of PPC. PPC patients were older (66.6 vs. 63.6 year, P = 0.038) and had higher amount of crystalloid (4200 vs. 3550 mL, P < 0.0001), and longer duration of anesthesia (670 vs. 625 min, P = 0.0062) than non-PPC patients. PPC patients were more likely to have had chronic obstructive pulmonary disease (COPD) (26.7 vs. 7.8%, P < 0.001). Incidence of PPC was significantly higher in patients with one-lung ventilation than with two-lung ventilation (37.1 vs. 15.3%, P < 0.001). Multivariable logistic regression analysis showed that PPC was associated with age (per 10 years, odds ratio (OR) = 1.41), COPD (OR = 3.43), one-lung ventilation (OR = 1.94), and volume of crystalloid (per 500 mL, OR = 1.22). CONCLUSIONS: Two-lung rather than one-lung ventilation should be chosen and fluid overload should be avoided in patients undergoing MIE in the prone position.

Effects of alveolar recruitment maneuver on end-expiratory lung volume during one-lung ventilation.

PURPOSE: To investigate the effects of alveolar recruitment maneuver (ARM) during one-lung ventilation (OLV) on end-expiratory lung volume (EELV) of the dependent lung. METHODS: Patients who were planned to undergo lung resection surgery for lung tumors and needed OLV for at least 1 h were included in the study. After turning the patients into the lateral position under total intravenous anesthesia, OLV was commenced using a double-lumen endobronchial tube. EELV was measured using the nitrogen washout technique at 20 min after OLV started (baseline) and 15, 30, 45, 60 min after ARM was performed on the dependent lung. RESULTS: Among 42 patients who completed the study, EELV increased at 15 min after ARM by 20% or greater compared with baseline in 21 patients (responders). Responders were significantly shorter in height (158 vs. 165 cm, p = 0.01) and had smaller preoperative functional residual capacity (2.99L vs. 3.65L, p = 0.02) than non-responders. Before ARM, responders had significantly higher driving pressure (14.2 vs. 12.4 cmH2O, p = 0.01) and lower respiratory system compliance (23.6 vs. 31.4 ml/cmH2O, p = 0.0002) than non-responders. Driving pressure temporarily dropped after ARM in responders, while no significant change was observed in non-responders. Fourteen out of 21 responders kept EELV 20% or more increased EELV than baseline at 60 min after ARM. CONCLUSION: EELV of the dependent lung was increased by 20% or greater in half of the patients responding to ARM. The increased volume of the dependent lung caused by ARM was maintained for 60 min in two-thirds of the responders.

Effects of acute kidney injury after liver resection on long-term outcomes.

BACKGROUND: To investigate the effects of acute kidney injury (AKI) after liver resection on the long-term outcome, including mortality and renal dysfunction after hospital discharge. METHODS: We conducted a historical cohort study of patients who underwent liver resection for hepatocellular carcinoma with sevoflurane anesthesia between January 2004 and October 2011, survived the hospital stay, and were followed for at least 3 years or died within 3 years after hospital discharge. AKI was diagnosed based on the Acute Kidney Injury Network classification within 72 hours postoperatively. In addition to the data obtained during hospitalization, serum creatinine concentration data were collected and the glomerular filtration rate (GFR) was estimated after hospital discharge. RESULTS: AKI patients (63%, P = 0.002) were more likely to reach the threshold of an estimated GFR (eGFR) of 45 ml/min/1.73 m2 within 3 years than non-AKI patients (31%) although there was no significant difference in mortality (33% vs. 29%). Cox proportional hazard regression analysis showed that postoperative AKI was significantly associated with the composite outcome of mortality or an eGFR of 45 ml/min/1.73 m2 (95% CI of hazard ratio, 1.05-2.96, P = 0.033), but not with mortality (P = 0.699), the composite outcome of mortality or an eGFR of 60 ml/min/1.73 m2 (P =0.347). CONCLUSIONS: After liver resection, AKI patients may be at higher risk of mortality or moderate renal dysfunction within 3 years. These findings suggest that even after discharge from the hospital, patients who suffered AKI after liver resection may need to be followed-up regarding renal function in the long term.

The Distribution of Phosphatidylcholine Species in Superficial-Type Pharyngeal Carcinoma.

Objectives. Superficial-type pharyngeal squamous cell carcinoma (STPSCC) is defined as carcinoma in situ or microinvasive squamous cell carcinoma without invasion to the muscular layer. An exploration of the biological characteristics of STPSCC could uncover the invasion mechanism of this carcinoma. Phosphatidylcholine (PC) in combination with fatty acids is considered to play an important role in cell motility. Imaging mass spectrometry (IMS) is especially suitable for phospholipid analysis because this technique can distinguish even fatty acid compositions. Study Design. IMS analysis of frozen human specimens. Methods. IMS analysis was conducted to elucidate the distribution of PC species in STPSCC tissues. STPSCC tissue sections from five patients were analyzed, and we identified the signals that showed significant increases in the subepithelial invasive region relative to the superficial region. Results. Three kinds of PC species containing arachidonic acid, that is, PC (16:0/20:4), PC (18:1/20:4), and PC (18:0/20:4), were increased in the subepithelial invasive region. Conclusion. These results may be associated with the invasion mechanism of hypopharyngeal carcinoma.

A case of unexpected impaired oxygenation due to intraoperative pneumothorax: an adverse event associated with respiratory management with spontaneous respiration in a patient with esophagobronchial fistulae.

BACKGROUND: Respiratory management in patients with esophagobronchial fistulae is challenging since positive pressure ventilation (PPV) may not be feasible due to air leaks and possible risks for regurgitation and aspiration of gastric contents. We and others have previously reported that spontaneous respiration may be one of the good options of respiratory management during general anesthesia in those patients. However, adverse events associated with this respiratory strategy have not been reported previously. We experienced a 77-year-old male patient who suffered unexpected impairment of oxygenation due to intraoperative pneumothorax, which was assumed to have been exacerbated by spontaneous respiration during esophageal bypass surgery. CASE PRESENTATION: The patient was planned to undergo esophageal bypass surgery for esophagobronchial fistulae associated with malignant esophageal cancer. Both of two esophagobronchial fistulae were located in the proximal part of the left main bronchus. For the risks of air leaks and aspiration associated with PPV and further damage to the tissue around the fistulae, we decided to maintain spontaneous respiration under general anesthesia and obtain abdominal muscle relaxation with epidural anesthesia. After catheterization of epidural anesthesia, the patient was sedated with 35 mg of intravenous pethidine and was nasotracheally intubated under bronchoscopic guidance. We confirmed that the tip of the tracheal tube was located above the carina. Then anesthesia was induced and maintained with sevoflurane so that his spontaneous respiration could be maintained thereafter. His spontaneous respiration was assisted with 3 cmH2O of pressure support. Approximately 60 min into the surgery, percutaneous arterial oxygen saturation (SpO2) suddenly dropped from 99 to 89% with an inspiratory fraction of oxygen of 0.4. We assumed that lung atelectasis associated with airway secretion or pulmonary soiling was the most likely reason for impaired oxygenation; however, arterial oxygenation only partially regained even after they were suctioned. After the completion of the surgery, chest X-ray revealed right pneumothorax. After a chest drainage tube was inserted, right pneumothorax was ameliorated and SpO2 returned to the baseline level. CONCLUSIONS: Although spontaneous respiration may be useful in a patient with esophagobronchial fistulae, oxygenation can be impaired more seriously than PPV in case intraoperative pneumothorax occurs.

Efficacy of Supraglottic Airway for Preventing Lung Injury Associated with Coughing at Extubation after Pulmonary Lobectomy.

BACKGROUND: The use of double-lumen endobronchial tubes (DLTs) is necessary for differential lung ventilation during pulmonary lobectomy. However, when used with conventional extubation procedures, coughing is more likely and is associated with an increased risk for parenchymal air leak along the staple line and possible subsequent lung injury. We examined the prevalence of coughing-associated air leaks at extubation and the efficacy of using supraglottic airways (SGAs) to prevent air leaks with post-lobectomy extubation. METHODS: This study included 150 patients with pulmonary emphysema diagnosed using preoperative computed tomography, who underwent pulmonary lobectomy between April 2010 and March 2015. The patients were chronologically enrolled in two groups: the DLT group (60 patients) from April 2010 to August 2012, and the SGA group (90 patients) from September 2012 to March 2015. (Note: the DLT group only included cases without air leak present just prior to extubation). Data were collected on specific patient characteristics and operative and postoperative factors. RESULTS: Coughing at extubation occurred in 15 (25.0 %) of 60 DLT patients, and parenchymal air leaks developed in 10 (66.7 %) of these 15. Comparison of groups revealed the SGA group was significantly lower for the following: patients with coughing at extubation (P < 0.001), coughing-associated air leaks at extubation (P < 0.001), air leaks >7 days (P = 0.006), reoperation due to air leaks (P = 0.013), and duration of chest tube drainage (P < 0.001). CONCLUSIONS: The SGA is effective for preventing air leaks associated with coughing during conventional DLT extubation in post-lobectomy patients.

Voice Outcome in Patients Treated With Endoscopic Laryngopharyngeal Surgery for Superficial Hypopharyngeal Cancer.

OBJECTIVES: Endoscopic laryngopharyngeal surgery (ELPS) is a minimally invasive transoral surgery that was developed to treat superficial larygo-pharyngeal cancer, in which a mucosal lesion is resected transorally while preserving deeper structures by subepithelial injection. The purpose of this retrospective study is to evaluate voice outcome in patients who underwent ELPS for superficial hypopharyngeal cancer. As important structures in producing voice, such as intrinsic laryngeal muscles, their fascia, and recurrent laryngeal nerve, are located in the medial side of the piriform sinus and the postcricoid region of the hypopharynx, we focused on patients with cancer lesions involving these regions. METHODS: From April 2010 to March 2011, 25 consecutive patients with superficial laryngopharyngeal cancer were treated with ELPS at Kyoto University Hospital. Among the 25 patients, 11 patients with cancer lesions on the medial side of the piriform sinus or the postcricoid area were studied. Preoperative and postoperative voice functions including maximum phonation time (MPT), mean flow rate (MFR), jitter, shimmer, soft phonation index (SPI), and noise-to-harmonic ratio (NHR), were compared retrospectively. RESULTS: Five of 11 cancer lesions had submucosal invasion and no lesion had invaded the muscular layer pathologically. T stage was classified as Tis in 5 cases, T1 in 4 cases, and T2 in 2 cases. All lesions involved the medial side of the piriform sinus and 2 also involved the postcricoid area. Vocal fold movement was normal in all cases after the surgery. Average preoperative and postoperative values for MPT, MFR, jitter, shimmer, SPI, and NHR, were 22.7 seconds and 23.4 seconds, 165 mL/sec and 150 mL/sec, 1.53% and 1.77%, 3.82% and 5.17%, 35.5 and 36.6, and 0.13% and 0.14%, respectively. There was no statistical difference between preoperative and postoperative data for all values examined. CONCLUSION: ELPS is useful in preserving voice function in the treatment of superficial hypopharyngeal cancer. Preserving the deeper structures including intrinsic muscles and their fascia may be important for preserving voice function as long as the lesions are superficial.

Successful Anesthesia Management for 2-Stage Surgical Procedure of a Refractory Tracheogastric Tube Fistula After Esophagectomy.

Tracheogastric tube fistulas are rare but fatal complications after esophagectomy. Anesthetic management for a patient with this complication is challenging because air leakage and mechanical ventilation may cause aspiration. We present a case report of the anesthetic management of a patient having 2-stage surgical repair combined with endoscopic mucosal resection for a giant carinal tracheogastric tube fistula. The first stage was separation of the gastric tube above the fistula with spontaneous breathing under local anesthesia and sedation. The second stage was complete separation and reconstruction of the digestive tract under epidural and general anesthesia with spontaneous breathing and pressure support before insertion of a decompression tube.

Endoscopic laryngo-pharyngeal surgery for superficial laryngo-pharyngeal cancer.

BACKGROUND AND STUDY AIMS: Narrow band imaging (NBI) combined with magnifying endoscopy enables us to detect superficial laryngo-pharyngeal cancers, which are difficult to detect by standard endoscopy. Endoscopic laryngo-pharyngeal surgery (ELPS) is a technique developed to treat such lesions and the purpose of this study is to evaluate the usefulness of ELPS for superficial laryngo-pharyngeal cancer. PATIENTS AND METHODS: Seventy five consecutive patients with 104 fresh superficial laryngo-pharyngeal cancers are included in this study. Under general anesthesia, a specially-designed curved laryngoscope was inserted to create a working space in the pharyngeal lumen. A magnifying endoscope was inserted transorally to visualize the field and a head & neck surgeon dissected the lesion using the combination of the orally-inserted curved grasping forceps and electrosurgical needle knife in both hands. The safely, functional outcomes, and oncologic outcomes of ELPS were evaluated retrospectively. RESULTS: Median operation time per lesion was 35 min. Post-operative bleeding occurred in 3 cases and temporal subcutaneous emphysema occurred in 10 cases. No vocal fold impairment occurred after surgery. The median fasting period was 2 days and all patients except one have a normal diet with no limitations. Local recurrence occurred in 1 case, and the 3-year overall survival rate and the 3-year disease specific survival rate was 90% and 100%, respectively. CONCLUSIONS: ELPS is a hybrid of head and neck surgery and gastrointestinal endoscopic treatment, and enjoys the merit of both procedures. ELPS makes it possible to perform minimally-invasive surgery, preserving both the swallowing and phonation functions.

Perioperative risk factors for acute kidney injury after liver resection surgery: an historical cohort study.

PURPOSE: This study aimed to identify the incidence and risk factors for acute kidney injury (AKI) after liver resection surgery and to clarify the relationship between postoperative AKI and outcome. METHODS: We conducted a historical cohort study of patients who underwent liver resection surgery with sevoflurane anesthesia from January 2004 to October 2011. Acute kidney injury was diagnosed based on the Acute Kidney Injury Network classification within 72 hr after the surgery. Patient data, surgical and anesthetic data, and laboratory data were extracted manually from the patients' electronic charts. Multivariable logistic regression analysis was used to identify perioperative risk factors for postoperative AKI. RESULTS: Acute kidney injury was diagnosed in 78 of 642 patients (12.1%; 95% confidence interval [CI]: 9.7 to 14.9). Multivariable analysis showed an independent association between postoperative AKI and preoperative estimated glomerular filtration rate (adjusted odds ratio [aOR] 0.74; 95% CI: 0.64 to 0.85), preoperative hypertension (aOR 2.10; 95% CI: 1.11 to 3.97), and intraoperative red blood cell transfusion (aOR 1.04; 95% CI: 1.01 to 1.07). Development of AKI within 72 hr after liver resection surgery was associated with increased hospital mortality, prolonged length of stay, and increased rates of mechanical ventilation, reintubation, and renal replacement therapy. CONCLUSION: Perioperative risk factors for AKI after liver resection surgery are similar to those established for other surgical procedures. Further studies are needed to establish causality and to determine whether interventions on modifiable risk factors can reduce the incidence of postoperative AKI and improve patient outcome. This study was registered at the University Hospital Medical Information Network (UMIN) Center (UMIN 000008089).

Magnifying endoscope with NBI to predict the depth of invasion in laryngo-pharyngeal cancer.

OBJECTIVES/HYPOTHESIS: To examine if macroscopic classification with a magnifying gastrointestinal endoscope with narrow band imaging (ME-NBI) is useful in predicting pathological depth of tumor invasion in laryngo-pharyngeal cancer. STUDY DESIGN: Retrospective study. METHODS: Preoperative endoscopy reports and postoperative pathological reports on 139 laryngo-pharyngeal cancer lesions were retrospectively reviewed, and the association between macroscopic findings in the lesions and the depth of tumor invasion was analyzed statistically. RESULTS: The ratios of lesions macroscopically classified as 0-I (superficial and protruding), 0-IIa (slightly elevated), 0-IIb (true flat), 0-IIc (slightly depressed), and 0-III (superficial and excavated) in the preoperative endoscopy reports were 3%, 25%, 71%, 1%, and 0%, respectively. Regarding the depth of tumor invasion in the postoperative pathological reports, the ratios of lesions classified as EP (carcinoma in situ), SEP (tumor invades subepithelial layer), and MP (tumor invades muscularis propria) were 73%, 26%, and 1%, respectively. The ratios of subepithelial invasion or muscular invasion in 0-I, 0-IIa, and 0-IIb were 100%, 54%, and 14%, respectively, and showed significant difference (P < 0.0001). Only one of 139 lesions invaded the muscular propria. CONCLUSIONS: This study is the first one to show that macroscopic findings by ME-NBI predict the depth of tumor invasion in superficial laryngo-pharyngeal cancer. It was indicated that there is a little chance of muscular invasion if the lesion is endoscopically diagnosed as 0-I or 0-II. A new T stage classification based on the depth of tumor invasion may be needed in order to adapt the classification to include transoral surgery. LEVEL OF EVIDENCE: 4.

Perioperative management of carinal pneumonectomy: a retrospective review of 13 patients.

Carinal pneumonectomy is a challenging procedure because of the difficulties in surgical technique, intraoperative airway management, and postoperative respiratory and anastomotic complications. However, information regarding the anesthetic and intraoperative respiratory management of this procedure is scarce. This report describes our routine anesthetic and respiratory management strategy in patients undergoing carinal pneumonectomy. Medical records of 13 patients who underwent carinal pneumonectomy under combined general and epidural anesthesia between 2008 and 2012 were analyzed retrospectively. Eleven patients underwent right carinal pneumonectomy and two underwent left carinal pneumonectomy. A left double-lumen tube was used in all but one case, in which endobronchial intubation was difficult because of intrabronchial invasion of the tumor. A 6.0-mm-long reinforced endobronchial tube was intubated into the main bronchus of the non-operative side from the surgical field during carinal resection. There were no episodes of severe hypoxemia or hypercapnia during surgery. Twelve patients were extubated immediately after surgery. No patient developed post-thoracotomy acute lung injury or required postoperative reintubation despite poor preoperative respiratory function. The 30-day mortality rate was 0%. Our airway management protocol for carinal pneumonectomy enables positive surgical outcomes.

Magnifying endoscopy with narrow band imaging to determine the extent of resection in transoral robotic surgery of oropharyngeal cancer.

Transoral robotic surgery (TORS) is a less invasive treatment that is becoming popular all over the world. One of the most important factors for achieving success in TORS is the ability to determine the extent of resection during the procedure as the extent of resection in the laryngopharynx not only affects oncological outcomes but also directly affects swallowing and voice functions. Magnifying endoscopy with narrow band imaging (ME-NBI) is an innovative optical technology that provides high-resolution images and is useful in detecting early superficial pharyngeal cancers, which are difficult to detect by standard endoscopy. A 55-year-old male with superficial oropharyngeal cancer has been successfully treated by combining MB-NBI with TORS and MB-NBI was useful in determining the extent of resection. ME-NBI with TORS will make it possible to achieve a higher ratio of minimally invasive treatment in pharyngeal cancer.