Serial Epithelial Lining Fluid Collection Using Bronchoscopic Microsampling in a Canine Lung Transplantation Model.

OBJECTIVES: As a less invasive alternative to bronchoalveolar lavage (BAL), bronchoscopic microsampling (BMS) was developed to identify molecules present in the epithelial lining fluid (ELF) of the distal airways. Here, we evaluated the utility of BMS for serial collection of ELF in a canine lung transplant model. METHODS: ELF was collected hourly by BMS up to 5 hours after reperfusion in a canine left lung transplant model. Tumor necrosis factor (TNF)-α levels in ELF were measured using an enzyme-linked immunosorbent assay and were compared with those in BAL fluid. RESULTS: Serial collection of ELF by BMS in graft lungs was possible without adverse effects. However, the partial pressure of oxygen was markedly decreased because of ischemia-reperfusion lung injury. Probe ELF absorption ranged from 1-18 µL. TNF-α expression was significantly elevated and detected for 5 hours after reperfusion, whereas it was very low in the sham-operated group (p < 0.05). TNF-α concentration in BAL fluid was less than one-hundredth of that in ELF. CONCLUSIONS: BMS was safe and effective for serial ELF collection in grafted lungs. Temporal changes in TNF-α corresponded with ischemia-reperfusion lung injury. This is the first study to adopt BMS to elucidate pulmonary function after lung transplantation.

[Thoracoscopic lobectomy as minimally invasive surgery].

There has always been a conflict between the proposition that surgical methods for treating lung cancer should completely remove the lesion and the seemingly contradictory proposition that they should be as minimally invasive as possible. The achievement of radicality has been pursued by specializing, and began in 1933 when Graham performed total pneumonectomy for lung cancer. In 1960, the current surgical "gold standard" for lung cancer was reached when anatomical lobectomy and lymph node dissection were performed by Cahan, and subsequently called "radical lobectomy." The pursuit of less invasiveness began in the early 1980s, after the achievement of radicality, and thoracoscopic lobectomy has been developed as a major advance. Thoracoscopic lobectomy differs only in the method of accessing the pleural cavity: the surgical procedure within the pleural cavity does not differ from the procedure for radical lobectomy. In addition, the outcome of patients who have undergone thoracoscopic lobectomy as a form of minimally invasive surgery has been reported to be better than that after open lobectomy, and it is now clear that thoracoscopic lobectomy contributes to improving patients' postoperative quality of life. Accumulating additional cases and further study will be necessary in the future.

Assessment of dyspnea in terminally ill cancer patients: role of the thoracic surgeon as a palliative care physician.

BACKGROUND: Many cancer patients suffer from rapidly-progressing dyspnea that is difficult to relieve. METHODS: The subjects were 26 patients who had dyspnea that was difficult to relieve. The Numeric Rating Scale was used to evaluate their dyspnea. For all patients, the cause of the dyspnea was investigated by CT and x-rays. RESULTS: The principal causes of the dyspnea were pleural effusion that increased daily, complications from pneumonia, massive ascites, multiple metastatic lung tumors and atelectasis, recurrent laryngeal nerve paralysis and narrowing secondary airway compression. Dyspnea was caused by a variety of conditions that overlapped over time, intensifying patients' discomfort. Among 14 patients for whom we recommended treatment with sedation, only 8 of them consented. Among the patients who were treated with sedation, the median interval between the exacerbation of dyspnea and death was 16 days; among non-sedated patients it was 18 days. CONCLUSIONS: Palliative care physicians who specialize in the respiratory system can, to some extent, predict the occurrence of rapidly progressive dyspnea in cancer patients. It is important to explain the methods of relieving dyspnea to the patient, the patient's family, and the oncologist early, so that decisions on how to manage dyspnea can be made in advance.

[A case of pain management using transdermal fentanyl patches for peritoneal carcinomatosis in a patient with small intestine stoma].

We experienced a patient with an ileal artificial anus who suffered from abdominal pain caused by peritoneal dissemination of ovarian cancer, for which slow-release oxycodone was ineffective, but fentanyl patch proved effective. The patient was a 28-year-old female who developed abdominal pain caused by peritoneal dissemination on postoperative day 60 after radical hysterectomy and colostomy. For pain relief, administration of 10-mg slow-release oxycodone and 180-mg loxoprofen sodium was begun. When the dose was increased to 25 mg on postoperative day 240, the slow-release oxycodone in its original form was confirmed in feces from the artificial anus.When the same drug was changed to a fentanyl patch(12. 5 mg/hr), the pain was relieved. A palliative care doctor needs much knowledge regarding the changes in the patient's body with the progress and treatment of cancer, in addition to the drug mechanism.

Diagnosis and treatment of deep pulmonary laceration with intrathoracic hemorrhage from blunt trauma.

BACKGROUND: Blunt chest trauma resulting in massive hemothorax requires immediate attention. We investigated the diagnostic and prognostic utility of various clinical factors in patients with deep pulmonary laceration caused by blunt chest trauma with a view toward interventional treatment. METHODS: We reviewed 42 patients with deep pulmonary laceration resulting from blunt chest trauma who were treated between 1988 and 2008. Various clinical factors were compared between survivors and nonsurvivors. RESULTS: Of the 42 patients, 29 (69%) survived. Median (25th, 75th percentile) systolic blood pressure at arrival was 102 (76, 121) mm Hg for survivors and 70 (60, 90) mm Hg for nonsurvivors (p = 0.015). The median heart rate at arrival was 107 (98, 120) beats/min for survivors and 130 (120, 140) beats/min for nonsurvivors (p = 0.014). Respiratory rate, Glasgow Coma Scale score, and arterial blood gas values did not affect prognosis. Blood loss through the chest tube at insertion was 500 (400, 700) mL for survivors and 700 (500, 1000) mL for nonsurvivors (p = 0.147) and within 2 hours of arrival was 850 (590, 1100) mm Hg and 1600 (1400, 2000) mL, respectively (p < 0.001). Blood loss during thoracotomy was 1170 (600, 1790) mL and 3500 (2000, 6690), respectively (p < 0.001). CONCLUSIONS: In patients with deep pulmonary laceration, hemorrhagic shock with systolic blood pressure less than 80 mm Hg and heart rate more than 120 beats/min leads to a poor prognosis. Emergency thoracotomy and pulmonary lobectomy should be performed before the intrathoracic hemorrhage reaches 1200 mL.

Ten cases of palliation of cancer pain with morphine.

OBJECTIVE: With the discovery of novel opioids in recent years, it has become feasible to alleviate various forms of cancer pain. If the characteristics of individual opioids are exploited depending on pain-related factors in cancer patients may yield satisfactory pain relief with a low incidence of adverse reactions. METHODS: This study involved 10 patients (5 male and 5 female) with cancerous abdominal pain, for whom the original opioid regimen was switched to morphine alone or continued in combination with morphine. The primary disease was gastric cancer in 5 patients, and uterine cervix, ovary cancer, leukemia, malignant pleuroperitoneal mesothelioma, and colon cancer in 1 patient each. Pain assessment was carried out using the Numerical Rating Scale. RESULTS: In all the 10 cases, the opioid administered first was fentanyl; the pain relief was inadequate. Satisfactory pain relief was achieved in all patients by switchover to morphine alone or by concomitant administration of morphine with fentanyl. CONCLUSION: Enhanced gastrointestinal motility accounts, at least in part, for cancerous abdominal pain. Further, this kind of pain can be relieved by suppression of gastrointestinal motility with morphine.

[The university hospital palliative care team's approach to the transfer of end-stage cancer patients from hospital care to home medical care].

The palliative care team's roles are to provide a symptom relief to cancer patients, help them accept their medical conditions, and offer advice regarding the selection of appropriate medical treatments to suit their needs. Seeking the comfort of their homes, patients prefer a home care of superior medical care provided at hospitals. In 2008, 25 of the end-stage cancer patients at hospitals were expressed their desires to have a home medical care, and 10 of them were allowed to do so. We considered the following contributing factors that a patient should have for a smooth transition from hospital care to home medical care: (1) life expectancy of more than 2 months, (2) no progressive breathing difficulties experienced daily, (3) good awareness of medical condition among patients and families, (4) living with someone who has a good understanding of the condition, (5) availability of an appropriate hospital in case of a sudden change in medical requirements, and (6) good collaboration between emergency care hospitals, home physicians, and visiting nurses. To treat the end-stage cancer patients at home, there is a need for information sharing and a joint training of physicians specialized in cancer therapy, palliative care teams, home physicians, and visiting nurses. This would ensure a sustainable "face-to-face collaboration" in community health care.

Endobronchial bleeding associated with blunt chest trauma treated by bronchial occlusion with a Univent.

BACKGROUND: Endobronchial bleeding in patients with blunt chest trauma can lead to death by suffocation. The conditions leading to bronchial bleeding usually require surgical treatment; however, for diffuse lung contusion, conservative treatment is possible if the bronchial bleeding can be controlled. METHODS: Sites, methods, and outcomes of occlusion of the affected bronchus by endobronchial blocker used with a Univent endotracheal tube (Fuji Systems Corporation, Tokyo, Japan) in 35 patients (29 men, 6 women; mean age, 26 +/- 13 years) with diffuse lung contusion, treated from 1988 to 2004, were analyzed. RESULTS: The right main bronchus was occluded in 7 patients, left main bronchus in 12, intermediate bronchial trunk in 9, and secondary bronchi in 7. Four patients who developed hypoxemia underwent differential ventilation. Bronchial occlusion was performed 118 +/- 139 minutes after arrival and continued 26 +/- 13 hours. Twenty-nine patients survived; 1 died of pulmonary abscess and 5 died due to brain injury. CONCLUSIONS: Bronchial occlusion should be performed soon after trauma in patients with endobronchial bleeding. The Univent has three advantages in such patients: (1) it prevents the inflow of blood from the affected bronchus into the unaffected lung; (2) the tamponade effect of the endobronchial blocker stops bronchial bleeding; and (3) air embolus due to air flowing from the bronchus into the pulmonary veins can be prevented. Use of a tube for one-lung ventilation with which the trauma surgeon is familiar is advisable. The Uniblocker tube (Fuji Systems Corporation) allows occlusion of the affected bronchus without reinsertion of a single-lumen tracheal tube.

Late diaphragmatic laceration detected as a result of spontaneous pneumothorax.

Injury to the right diaphragm is sometimes missed in the acute stage and is detected only when the rupture becomes more extensive, a diaphragmatic hernia develops, and dyspnea ensues. We report a case in which spontaneous right pneumothorax developed 46 months after blunt trauma due to a fall. Air had leaked into the right pleural cavity, passed through the injured right diaphragm, and entered the abdominal cavity; the patient presented with intraperitoneal emphysema.

Treatment with internal pneumatic stabilization for anterior flail chest.

OBJECTIVE: Advantages and disadvantages have been reported for both internal pneumatic stabilization and surgical stabilization as treatments for anterior flail chest. We retrospectively investigated therapeutic outcomes and problems associated with pneumatic stabilization for anterior flail chest patients. METHODS: Subjects were 43 patients admitted to Tokai University Hospital with anterior flail chest, 1988-1999. Pneumatic stabilization was performed with continuous positive pressure ventilation and a positive end-expiratory pressure of 10 cm H20 or higher. We analyzed mean times required for pneumatic stabilization, weaning, and mechanical ventilation; sternal fracture (presence vs. absence); survival, and other clinical variables. RESULTS: Continuous positive pressure ventilation was needed for 12.5 days and mechanical ventilation for 15.6 days. Flail chest was relieved by pneumatic stabilization alone in 42 patients; 1 patient with a displaced sternal fracture required sternal fixation. Four cases were complicated by pneumonia. Pneumatic stabilization allowed physicians to treat severe combined nonthoracic organ injuries during the acute phase. Forty patients survived, and 3 died from nonthoracic injuries (survival rate 93%). CONCLUSIONS: Anterior flail chest unaccompanied by sternal fracture can be relieved by pneumatic stabilization alone. We hope to combine pneumatic stabilization with simple surgical stabilization in anterior flail chest patients to shorten the mechanical ventilation period.

Life-saving treatment by fluid resuscitation and a thoracotomy in a case of deep pulmonary laceration.

CASE: A 41-year-old man survived deep pulmonary and hepatic lacerations by treatment with fluid resuscitation, blood transfusion, thoracotomy, and transcatheter hepatic artery embolization. The patient was transferred to our hospital 46 minutes after his motorbike struck a station wagon from behind. Hemorrhagic shock with systolic blood pressure of 68 mmHg was observed. He showed nonresponse to 20-minute intravenous infusion of 1,500 mL of lactated Ringer's solution. The initial plain chest radiograph showed mediastinal deviation to the left, radio-opacity of the right lower lobe, and decreased radiolucency of the right thorax. Rapid drainage of 800 mL of blood through a right chest tube led to a diagnosis of a deep pulmonary laceration of the right lower lobe. Abdominal computed tomography revealed another deep laceration affecting 40% of the liver. A right lower lobectomy of the lung was performed at 169 minutes after arrival. After the thoracotomy,transcatheter arterial embolization of the right hepatic artery was performed. The patient was discharged on hospital day 57. CONCLUSION: Prompt diagnosis and appropriate treatment are necessary to save patients with multiple, severe blunt injuries. Advanced Trauma Life Support (ATLS) guidelines should be adhered to for appropriate early treatment of patients with severe trauma.

Video-assisted thoracoscopic surgery in treatment of stabbing chest injuries.

Since 1994, we have performed video-assisted thoracoscopic surgery in order to treat thoracic trauma. In general, emergency surgery is performed for trauma injuries incurred by knives. Between 1994 and 2005, we performed thoracoscopic surgery on eighteen cases of thoracic stab wounds. Among these eighteen cases, two were characterized by wounds to the internal thoracic artery, and they had to be switched over to open thoracotomy due to excessive bleeding. In conclusion, open thoracotomy should be performed in cases in which the patient is in a state of shock due to severe intrathoracic bleeding; however, in cases in which the vital signs are stable, thoracoscopic surgery may be carried out to stop intrathoracic bleeding, to repair the lung injury by suturing, as well as by performing a partial resection of the lung.

Occult neoplastic cells in the lymph node sinuses and recurrence of primary breast, lung, esophageal, and gastric cancer.

The correlation between detection of occult neo-plastic cells (ONCs) in lymph node sinuses and the recurrence/metastasis of primary breast, lung, esophageal, and gastric cancer was examined. Among patients with Stage I-III cancer treated by radical resection with dissection of at least 10 lymph nodes, 40 patients who suffered recurrence/metastasis within 5 years post-operatively and 94 patients who did not have recurrence within 5 years were randomly selected. A total of 1,340 lymph nodes were subjected to immunohistochemical staining for cytokeratin to identify ONCs. Then the sensitivity, specificity, positive predictive value, and negative predictive value of ONCs were determined for predicting the recurrence of each cancer. These parameters were respectively 40.0, 75.9, 62.4, and 55.8% for breast cancer, while the respective values were 50.0, 77.4, 68.9, and 60.8% for lung, 57.1, 64.3, 61.5, and 60.0% for esophageal, and 68.8, 65.0, 66.3, and 67.5% for gastric cancer. All of the parameters exceeded 65% for gastric cancer. ONCs also showed a high specificity for breast and lung cancer, but both the sensitivity and specificity were low for esophageal cancer.

Use of 11p15 mucins as prognostic factors in small adenocarcinoma of the lung.

PURPOSE: Patients with small adenocarcinoma of the lung (SACL) generally have a good prognosis. However, some SACL cases show lymph node metastasis, with poor prognosis. The expression pattern of 11p15 mucins (clustered on the p15 arm of the chromosome 11) is known to change during carcinogenesis in lung cancer. EXPERIMENTAL DESIGN: We evaluated the expression of the 11p15 mucins (MUC2, MUC5AC, and MUC6) in 79 surgical specimens of SACL cases by immunohistochemical analysis. Lymph node metastasis was estimated by pathological staging. RESULTS: Six (7.6%) and 11 (13.9%) of the 79 SACL cases showed MUC2 and MUC6 expression, respectively. Three SACL cases showed both MUC2 and MUC6 expression, and a significant correlation was found between MUC2 and MUC6 expression (Fisher's test, P = 0.033). Six (7.6%) SACL cases showed MUC5AC expression. Five of the 6 cases with MUC2 expression and 6 of the 11 cases with MUC6 expression were had lymph node metastasis. SACL cases with MUC2 or MUC6 expression showed a significantly higher incidence of nodal metastasis than those without expression (P < 0.001 and P = 0.006, chi(2) test, respectively). There was no significant correlation between MUC5AC expression and nodal involvement in SACL, whereas three of the six cases with MUC5AC expression showed lymph node metastasis. The SACL cases with MUC2 expression had a significantly poorer prognosis than those without MUC2 expression (P = 0.011, log-rank test). CONCLUSIONS: These results suggest that 11p15 mucins MUC2 and MUC6 are related to lymph node metastasis in SACL.