Main right hepatic duct entering the cystic duct: a case report.

BACKGROUND: Risk factors for bile duct injury in laparoscopic cholecystectomy include severe inflammation at Calot's triangle and aberrant bile duct variations. Knowledge of the various biliary anomalies and early identification may therefore assist in decreasing the rate of bile duct injury. CASE PRESENTATION: A 65-year-old woman was admitted with right hypochondrial pain and high fever. A diagnosis of acute calculous cholecystitis was made by radiological imaging. Magnetic resonance cholangiopancreatography revealed that the confluence of the right and left hepatic duct was unclear. Intraoperatively, the procedure was converted from a laparoscopic cholecystectomy to laparotomy because of unclear anatomy of the cystic duct with severe inflammation at Calot's triangle. Furthermore, intraoperative cholangiography from Hartmann's pouch showed the main right hepatic duct entering the cystic duct. Subtotal cholecystectomy was performed to avoid injuring the right hepatic duct. CONCLUSION: Although an aberrant hepatic duct entering the cystic duct is not uncommon, the main right hepatic duct infiltrating the cystic duct is extremely rare. Preoperative and intraoperative evaluation of the biliary duct and awareness of aberrant biliary duct variations is important in preventing bile duct injury.

Early and Mid-Term Outcomes Following TEVAR for Chronic Type B Aortic Dissection.

We examined the outcomes of aortic remodeling for chronic type B aortic dissection (cTBD) after thoracic endovascular aneurysm repair (TEVAR). Objective & Methods: Thirty-eight patients underwent TEVAR for cTBD at our institution. We classified cTBD patients into the early cTBD group (16 cases, 2 weeks-4 months from onset) and late cTBD group (22 cases, >4 months from onset). Results: There were no cases of paraplegia, stroke, and hospital death in both groups. There was no worsening of complicated cases. We achieved false lumen thrombosis in cases with a double-barreled thoracic aorta. The early cTBD group had more complete shrinkage cases (60%) than the late cTBD group (11%). Conclusion: We obtained favorable mid-term outcomes after TEVAR for cTBD patients. Early cTBD patients obtained good aortic remodeling with TEVAR. (This is a translation of Jpn J Vasc Surg 2016; 25: 233-239.).

Chimney technique for aortic dissection involving an aberrant right subclavian artery.

We report a case involving a ruptured acute type B aortic dissection originating from an aberrant right subclavian artery (ARSA). A thoracic stent-graft was deployed in the distal arch close to the origin of the ARSA; the entry site at the origin of the ARSA was embolized with metallic coils. Perfusion of the left subclavian artery was preserved without a surgical bypass by using a chimney graft. This procedure is a feasible and less invasive treatment for high-risk sternotomy patients and is an effective strategy for acute aortic dissections involving an ARSA.

Single-stage thoracic and abdominal endovascular aneurysm repair for multilevel aortic disease.

This investigation evaluated the results of single-stage thoracic endovascular aneurysm repair (TEVAR) and endovascular aneurysm repair (EVAR) for multilevel aortic disease in a series of nine patients. The lesions repaired included thoracic and abdominal aortic aneurysms (n= 7) and subacute type B dissections with abdominal aortic aneurysms (n=2). All procedures were successfully performed, and none of the patients experienced postoperative stroke or spinal cord ischemia. The median follow-up period for these patients was 18.9 months (range 1.7-31.4 months) and none of the patients exhibited any signs of type I endoleaks or aneurysmal diameter enlargements more than 5 mm. In conclusion, single-stage TEVAR and EVAR procedures for multilevel aortic disease were found to be safe and feasible modalities for high-risk patients.

Endovascular repair of distal arch aneurysm with double-chimney technique.

We report 2 cases of distal arch aneurysm treated by thoracic endovascular aneurysm repair (TEVAR) with the "double-chimney technique." This technique permitted the implantation of a thoracic stent graft in the ascending aorta over the arch branches while preserving perfusion of innominate and left common carotid arteries without debranching bypasses. The procedure is a feasible and less invasive treatment for distal arch aneurysm with a short proximal neck (<2 cm to the origin of the innominate artery) in patients at high risk when undergoing sternotomy and in emergent cases.

[A recurrent case of lipid-secreting carcinoma of the breast successfully treated with capecitabine].

We herein report a recurrent case of lipid-secreting carcinoma of the breast which was successfully treated with capecitabine. A 50-year-old female underwent a pectoralis-preserving mastectomy for left breast cancer in December 2002. The clinical staging of the disease was T2N1M0 (stage II B) and ER (-), PgR(-), HER2 (1+). Microscopic examinations revealed solid alveolar proliferation in the majority of the tumor cells, which had an abundant foamy cytoplasm. A variable amount of neutral lipid was also identified in the cytoplasm of the tumor cells by Sudan III staining. After the operation, the patient received two courses of systemic chemotherapy using docetaxel (60 mg/m(2)). In March 2004, she was diagnosed to have a recurrence in the thoracic wall. She received radiotherapy (total 50 Gy radiation), but it proved to be ineffective. In June 2004, treatment using capecitabine (2,400 mg/day) was therefore attempted. Two courses of the treatment resulted in a complete response of the tumor. The above patient has since continued to show a complete response with capecitabine for over 3.5 years.

Breath-hold single-photon emission tomography and computed tomography for predicting residual pulmonary function in patients with lung cancer.

OBJECTIVE: We sought to evaluate the utility of integrated breath-hold single-photon emission tomography and computed tomography imaging compared with that of simple calculation with the lung segment-counting technique for predicting residual pulmonary function in patients undergoing surgical intervention for lung cancer. METHODS: A prospective series of 22 patients undergoing anatomic lung resection for cancer were enrolled in this study. Postoperative residual forced expiratory volume in 1 second was predicted by measuring the radioactivity counts of the affected lobes or segments to be resected within the entire lungs by placement of regions of interest on single-photon emission tomography and computed tomography images. Residual forced expiratory volume in 1 second was also estimated by using the segment-counting technique. RESULTS: Both predicted values agreed well with postoperative forced expiratory volume in 1 second. Although the residual forced expiratory volume in 1 second predicted by means of single-photon emission tomography and computed tomography correlated well with that predicted by using segment counting, the values were significantly underestimated by the segment-counting technique in 4 outliers with severe emphysema. There were 2 patients with borderline pulmonary functional reserve whose residual forced expiratory volume in 1 second values were predicted more accurately by means of single-photon emission tomography and computed tomography than by using segment counting. CONCLUSION: Integrated breath-hold single-photon emission tomography and computed tomography images allow the accurate prediction of postoperative pulmonary function but without statistical superiority over the simple segment-counting technique. Further study of the usefulness of single-photon emission tomography and computed tomography in patients with severe emphysema and borderline lung function should prove valuable because the segment-counting technique underestimates pulmonary functional reserve in these patients.

Successful treatment of intracardiac progression and metachronous multiple brain metastases from primary lung cancer.

We report a rare case of squamous cell carcinoma of the lung extending into the left atrium via the pulmonary vein. The tumor tissue including the thrombus was resected en-bloc under cardiopulmonary bypass. Despite adjuvant chemotherapy, multiple brain metastases developed, but they were eradicated by stereotactic radiosurgery. The patient is still disease-free 48 months after the resection. This case serves to demonstrate the validity of multidisciplinary treatment for locally advanced lung cancer.

Cerebral air embolism during imaging of a sentinel lymphatic drainage in the respiratory tract.

We report a rare but notable case of cerebral air embolism complicating transthoracic intrapulmonary injection of an imaging agent used to locate sentinel lymph nodes. After a bolus injection of 2 mL of iopamidol into the peritumoral area with a 23-gauge needle, the patient complained of complete paralysis on his left side. Intraaortic gas was detected by computed tomography immediately after the injection. The patient recovered spontaneously without any additional complication. Surgeons should be aware of this rare but possible complication during sentinel lymph node assessment.

Relationship among Genetic Alterations, DNA Content, and Clinicopathological Features in Primary Lung Adenocarcinomas.

BACKGROUND: Only fragmentary information is available about the genomic imbalances affecting the malignant potential of lung cancers. PATIENTS AND METHODS: Chromosomal DNA sequence copy number aberrations (DSCNAs) and DNA content (ploidy status) were examined in 34 resected tumor specimens, using comparative genomic hybridization and laser scanning cytometry, respectively. RESULTS: Twenty-seven tumors showed DNA aneuploidy. Gains of 9q22-33 and 10q26-qter and loss of 15q14-qter were the significant indicators of lymph node metastasis. These DSCNAs were identified only in aneuploid tumors. Aneuploid tumors with any of these DSCNAs were associated with a worse prognosis than those not associated with any of these DSCNAs. The DNA index was a significant prognosticator in aneuploid tumors, although it was not dependent on the level of genetic alterations. CONCLUSION: Clinically-relevant genetic alterations were identified predominantly in aneuploid tumors. The DNA content also affected the prognosis of patients with aneuploid tumors. Thus, a comprehensive genomic study of aneuploid lung adenocarcinomas should be of great clinical value.

Genomic alterations detected by comparative genomic hybridization in primary lung adenocarcinomas with special reference to the relationship with DNA ploidy.

To clarify the clinicopathological and biological significance of genomic alterations in pulmonary adenocarcinomas, we examined chromosomal DNA sequence copy number aberrations (DSCNAs) and DNA ploidy in 42 surgically resected specimens by comparative genomic hybridization (CGH) and laser scanning cytometry (LSC), respectively. The number of DSCNA did not affect the size of carcinoma or number of nodal metastasis. More than 60% of carcinomas showed a 1q21-23 gain or 13q21 loss. Gains of 9q22-33 and 10q26-qter and a loss of 15q14-qter were significantly associated with nodal metastasis (p<0.05). Of 42 pulmonary adenocarcinomas, 32 (76%) showed DNA aneuploidy. The number of DSCNAs in aneuploid carcinomas was larger than that in diploid carcinomas (p<0.01). Our results suggest that diploid and aneuploid types are cytogenetically different in pulmonary adenocarcinomas and aneuploid carcinomas are genetically more unstable and aggressive than diploid carcinomas.

Role of quantitative CT in predicting hypoxemia and complications after lung lobectomy for cancer, with special reference to area of emphysema.

STUDY OBJECTIVES: To determine the ability of quantitative CT, with special reference to area of emphysema, to predict early postoperative oxygenation capacity and outcome after lung lobectomy for cancer. METHODS: Sixty-two consecutive patients scheduled to undergo lung lobectomy for cancer were enrolled in this study. The area of emphysema (< - 910 Hounsfield units) was measured on a three-dimensional CT lung model. Arterial oxygen saturation (Sao(2)) was calculated from Pao(2) measured 1 day before and 1 day after surgery with patients at rest breathing room air. A patient was considered to have recovered at the completion of a standardized management regimen. RESULTS: Postoperative Sao(2) (postSao(2)) was predicted by the baseline value and the area of emphysema with the use of a regression equation. Ten of the 62 patients (16%) had postoperative cardiopulmonary complications (CPCs). The median time to postoperative recovery was 3 days (range, 1 to 17 days). Predicted postSao(2) and predicted postoperative FEV(1) were shown to be significant independent predictors of postoperative CPCs as well as postoperative recovery time. CONCLUSION: Determining the area of emphysema by quantitative CT is useful in predicting early postoperative oxygenation capacity. Predicted oxygenation capacity and predicted ventilatory capacity independently affect perioperative outcomes. Therefore, using quantitative CT in combination with spirometry may improve risk prediction in patients undergoing lung lobectomy for cancer. However, the role of quantitative CT in grading nonemphysematous lung diseases, such as interstitial lung diseases, must be investigated.

Quantitative computed tomography versus spirometry in predicting air leak duration after major lung resection for cancer.

BACKGROUND: Emphysema is a well-known risk factor for developing air leak or persistent air leak after pulmonary resection. Although quantitative computed tomography (CT) and spirometry are used to diagnose emphysema, it remains controversial whether these tests are predictive of the duration of postoperative air leak. METHODS: Sixty-two consecutive patients who were scheduled to undergo major lung resection for cancer were enrolled in this prospective study to define the best predictor of postoperative air leak duration. Preoperative factors analyzed included spirometric variables and area of emphysema (proportion of the low-attenuation area) that was quantified in a three-dimensional CT lung model. Chest tubes were removed the day after disappearance of the air leak, regardless of pleural drainage. Univariate and multivariate proportional hazards analyses were used to determine the influence of preoperative factors on chest tube time (air leak duration). RESULTS: By univariate analysis, site of resection (upper, lower), forced expiratory volume in 1 second, predicted postoperative forced expiratory volume in 1 second, and area of emphysema (< 1%, 1% to 10%, > 10%) were significant predictors of air leak duration. By multivariate analysis, site of resection and area of emphysema were the best independent determinants of air leak duration. The results were similar for patients with a smoking history (n = 40), but neither forced expiratory volume in 1 second nor predicted postoperative forced expiratory volume in 1 second were predictive of air leak duration. CONCLUSIONS: Quantitative CT is superior to spirometry in predicting air leak duration after major lung resection for cancer. Quantitative CT may aid in the identification of patients, particularly among those with a smoking history, requiring additional preventive procedures against air leak.

Video-assisted transcatheter lung perfusion regional chemotherapy.

OBJECTIVE: To establish a technique for performing isolated lung perfusion (ILP) under video-assisted thoracic surgery (VATS) to treat unresectable lung malignancies. METHODS: Under fluoroscopic and thoracoscopic guidance, five canine left lungs were isolated by means of an endovascular technique comprising pulmonary artery cannulation through the right femoral vein and pulmonary vein cannulation through the left auricular appendage (VATS-ILP). ILP was performed for 20 min at a flow rate of 30 ml/min with a high-dose cisplatin solution (50 microg/ml). Toxicity and pharmacokinetics of VATS-ILP were compared with those of conventional ILP performed in five additional lungs. RESULTS: VATS-ILP was performed safely without adverse reaction. Both VATS-ILP and conventional ILP delivered a high dose of cisplatin to the treated lung (total platinum concentration: 48+/-17 microg/g tissue for VATS-ILP vs. 51+/-19 microg/g tissue for conventional ILP, P>0.1) without significant systemic leakage (total platinum concentration: 0.4+/-0.1 microg/ml plasma vs. 0.5+/-0.2 microg/ml plasma, P>0.1). In addition, no significant differences were observed between the groups in the serum lactate dehydrogenase level, serum angiotensin-converting enzyme level, body weight change, or mid-term histological change following ILP. A significantly smaller thoracotomy was used for VATS-ILP than for conventional ILP (4.7+/-0.4 cm for VATS-ILP vs. 12+/-0.7 cm for conventional ILP, P<0.001) because VATS-ILP required neither arteriotomy nor venotomy. CONCLUSIONS: We established a canine VATS-ILP model that showed pharmacokinetic potential similar to that of conventional ILP. A clinical trial of VATS-ILP with cytotoxic drugs is warranted.

Prediction of hypoxemia after lung resection surgery.

Pulmonary resection under general anesthesia induces various degrees of hypoxemia that adversely impacts on postoperative recovery. Consecutive of 53 patients undergoing anatomical pulmonary resection were enrolled in this study to accurately define predictors of postoperative hypoxemia. Preoperative variables studied included spirometric variables, blood gases, and extent of low attenuation area (below -910 Hounsfield units) on a three-dimensional computed tomography lung model. Arterial oxygen saturation was calculated from arterial partial pressure of oxygen measured 1 day before and 1 day after surgery with patients at rest breathing room air. Postoperatively, the patients were managed according to a standardized regimen. According to stepwise multiple regression analysis, preoperative oxygen saturation and the extent of low attenuation area were selected as the best predictors of postoperative oxygen saturation. Regression equation was generated with these two variables. The predicted postoperative oxygen saturation was significantly dependent on the length of management (P<0.01). Using a radiographic parameter, we established a novel means of predicting postoperative hypoxemia that impacted on postoperative recovery. Because this radiographic parameter was superior to conventional spirometric variables for prediction of postoperative hypoxemia, further confirmation of its usefulness in predicting risk after pulmonary resection is warranted.

Computed tomography lymphography with intrapulmonary injection of iopamidol for sentinel lymph node localization.

PURPOSE: Experimental and clinical evaluation of the potential utility of indirect computed tomographic lymphography (CT-LG) with intrapulmonary injection of iopamidol for preoperative localization of sentinel lymph node station in non-small cell lung cancer. METHODS: CT-LG with intrapulmonary injection of 0.5 mL of undiluted iopamidol was performed in 10 dogs using a multidetector-row CT unit, followed by postmortem examination of enhanced lymph nodes in 5 of these dogs. The CT-LG with peritumoral injection of 1 mL of the contrast agent was also performed in 9 patients with non-small cell lung cancer without lymphadenopathy. At surgery, enhanced lymph nodes were resected under CT-LG guide, followed by standard lymph node dissection with macroscopic and histologic examination. A significant enhancement of lymph nodes was determined when CT attenuation value was increased with 30 Hounsfield units (HU) compared with precontrast images. RESULTS: CT-LG visualized a total of 15 enhanced lymph nodes (on average, 1.5 nodes per animal) within 2 minutes after contrast injection in the 10 dogs, with average size of 6.7+/- 1.9 mm and average maximum CT attenuation of 149 +/- 41 HU. All the 8 enhanced nodes in 5 dogs were found in the appropriate anatomic locations in postmortem examinations. Without noticeable complications, CT-LG visualized 30 ipsilateral intrathoracic lymph nodes including 19 hilar/pulmonary and 11 mediastinal nodes in the 9 patients (on average, 2.2 hilar/pulmonary and 1.1 mediastinal nodes per patient) within 2 minutes after contrast injection, with average size of 4.7+/- 0.4 mm and average maximum CT attenuation of 134 +/- 52 HU. At surgery, all these enhanced nodes could be accurately found and resected under CT-LG guidance. Metastasis was not evident in either of these enhanced lymph nodes or the remaining distant nodes in all patients. CONCLUSION: Quick and accurate localization of sentinel lymph node station on detailed underlying lung anatomy by using indirect CT-LG may be of value to guide selective lymph node dissection for minimally invasive surgery in non-small cell lung cancer.

Preoperative imaging of the lung sentinel lymphatic basin with computed tomographic lymphography: a preliminary study.

BACKGROUND: Preoperative localization of the sentinel node basin would guide selective lymph node dissection. We tried to identify these nodal stations with indirect computed tomographic lymphography using a conventional extracellular contrast agent, iopamidol. METHODS: Eleven consecutive patients scheduled to undergo anatomic resection of suspected lung cancer, without lymphadenopathy, were given a peritumoral injection of undiluted iopamidol under computed tomography guidance, and lymphatic migration was assessed by multidetector-row helical computed tomography. RESULTS: There were no complications such as bleeding, pneumothorax, or allergic reactions. Enhanced nodes were detected in all but 1 patient who had diffuse lymph nodal calcification. Enhanced nodes were identified at 32 ipsilateral intrathoracic nodal stations (20 hilar stations and 12 mediastinal stations). The average length of the longer axis of the enhanced nodes was 4.8 mm (range, 3 to 8 mm), and the average attenuation of the enhanced nodes was 132 (range, 46 to 261) Hounsfield units. In 9 patients with confirmed lung cancer, enhanced nodes appeared at 26 nodal stations, and all apparent enhanced nodes were identified as actual lymph nodes at appropriate position during lymphadenectomy. None of the resected lymph nodes had metastatic involvement. CONCLUSIONS: Indirect computed tomographic lymphography with the peritumoral injection of iopamidol effectively depicts the drainage nodes unless they are diffusely calcified. Although further study is required, this method could guide selective lymph node dissection.

Radioisotope lymph node mapping in nonsmall cell lung cancer: can it be applicable for sentinel node biopsy?

BACKGROUND: Previous studies on intrathoracic lymph node mapping have focused on the validity of a sentinel node concept, but not on the usefulness for sentinel node biopsy. METHODS: The subjects were 15 patients clinically diagnosed with N0 nonsmall cell lung cancer. Technetium-99m tin colloid was injected into the peritumoral area 1 day preoperatively and a time course of tracer migration was monitored by scintigraphy. A hand-held gamma probe counter was used to count the intrathoracic lymph node stations. Resected nodes were also counted to assess the accuracy of the intrathoracic counting. RESULTS: Serial scintigraphies showed that the tracer migrated through airways and the appearance resembled hot nodes. On intrathoracic counting, 50% of the nodal stations appeared positive; however, only 23% of these apparently positive nodal stations were ultimately shown to be truly radioactive. The true positive and true negative rates of detecting intrathoracic hot nodes were 100% and 56%, respectively. Because the counts of the nodal stations could include the counts from the hot primary tumor ("shine-through") or airway radioactivity, legitimate hot nodes were identified after dissecting all the apparently positive nodal stations. Two of the 9 patients in whom hot nodes were identified had nodal metastatic disease and actually had tumor cells within the hot nodes. The only complication related to the preoperative injection of technetium-99m was a minor pneumothorax. CONCLUSIONS: Although radioisotope intrathoracic lymph node mapping is safe, it appears to be unsuitable for sentinel node biopsy because shine-through and the airway-migrated radioactive tracer complicated the intrathoracic counting. Only serial scintigraphy could distinguish hot nodes from airway migration.

Obstacles for shortening hospitalization after video-assisted pulmonary resection for lung cancer.

BACKGROUND: Video-assisted thoracic surgery for lung cancer facilitates early postoperative recovery when patients are treated by critical pathway management. Thus, we developed an original programmed regimen for postoperative management, evaluated the validity of this regimen, and analyzed clinical factors influencing postoperative recovery. METHODS: Forty consecutive patients with suspicious lung cancer undergoing anatomic pulmonary resection with video-assisted thoracic surgery were enrolled in this prospective study. After surgery, all patients who underwent anatomic resection were managed using our programmed regimen; a patient was considered recovered when the regimen had been completed. RESULTS: On final pathologic examination, 37 cases were determined to have lung cancer and underwent anatomic resection. The mean number of resected segments was 3.6. There were no complications caused by postoperative management. The mean day of postoperative recovery was 3.7 days and median, 3 days. Significant preoperative factors related to recovery were age, breathlessness, performance status, radiologic emphysema, partial pressure of arterial oxygen, and predictive postoperative forced expiratory volume in 1 second. The overall number of these risk factors was specifically related to postoperative recovery (p < 0.01): the rate of recovery on postoperative day 3 was 100% in patients with no risk, 68% in those with one to three risks, and 22% in those with four to six risks. CONCLUSIONS: Our original regimen is useful as a critical pathway for the management of lung cancer patients undergoing video-assisted thoracic surgery. Furthermore, we created specific criteria to identify risk factors related to postoperative recovery that may be useful in planning hospitalization for patients undergoing video-assisted thoracic surgery.

Effect of radioisotope sentinel node mapping in patients with cT1 N0 M0 lung cancer.

BACKGROUND: Application of the sentinel node concept to lung cancer is still controversial. Patients with peripheral small lung cancers would gain the most benefit from this concept, if it were valid. We sought to determine whether it is possible to choose between limited lymph node sampling and systematic lymphadenectomy from the distribution of sentinel lymph nodes in patients with node-negative disease on the basis of imaging. METHODS: Sixty-five consecutive patients with cT1 N0 M0 non-small cell lung cancer were enrolled. A radioisotope tracer (4 mCi of technetium-99m tin colloid, 2.0 mL) was injected in the vicinity of the tumor before surgical intervention with computed tomographic guidance. The radioactivity of each resected lymph node was measured separately with a hand-held gamma probe after complete tumor resection. Sentinel nodes were identified, and the accuracy of sentinel node mapping was examined. Whether the location of the sentinel node depended on the site of the primary tumor was also examined. RESULTS: Of the 65 patients, 3 were excluded because of the final pathologic results. Successful radionuclide migration occurred in 39 (62.9%) of the 62 patients. There was 1 (2.6%) false-negative result among 39 patients with a sentinel node, and therefore the sensitivity was 90%, and the specificity was 100%. The most common sentinel lymph nodes were at level 12 (46.7%), followed by level 11 (18.3%), the mediastinum (16.7%), and level 10 (11.7%). CONCLUSION: The sentinel node concept is valid in patients with cT1 N0 M0 lung cancer. The lobar lymph nodes were identified as sentinel nodes more frequently than other lymph nodes. We need to make further efforts to increase the sentinel node identification rate. However, we believe that if sentinel nodes are identified, sentinel node mapping can allow the accurate intraoperative diagnosis of pathologic N0 status in patients with cT1 N0 M0 lung cancer.