Multidisciplinary treatment of thoracic fistulous empyema caused by pulmonary infection: a retrospective study.

Background: In cases of thoracic empyema, the presence of a fistula is known to be difficult to treat and associated with a poor prognosis. Few reports have described the management of fistulous empyema caused by lung parenchymal infection. The aim of this study was to describe the outcomes of multidisciplinary management of fistulous empyema caused by pneumonia or lung abscess due to common bacteria and mycobacteria. Methods: Among 108 cases of empyema surgically treated at Kanagawa Hospital over a 10-year period, 14 patients with fistulous empyema due to common bacteria (CBFE) or fistulous empyema due to mycobacteria (MFE) were analyzed. Fistulous empyema due to lung resection was excluded. Results: Eight out of the 9 patients with CBFE and 4 out of the 5 patients with MFE were male. Patients with CBFE were more likely to be >65 years of age (p=0.052) and to have a poor performance status (p=0.078). The time from onset to first surgical treatment was significantly longer in MFE (median, 5 months; p=0.004). Five patients with CBFE and two patients with MFE underwent open window thoracostomy, while three patients with CBFE and four patients with MFE underwent endobronchial occlusion (EBO). Six patients (66%) with CBFE and 3 patients (60%) with MFE achieved fistula closure. Of the patients who underwent EBO, fistula closure was achieved in 3 (100%) of the patients with CBFE and in 2 (50%) of the patients with MFE. Fistula closure was not achieved in any case with non-tuberculous mycobacteria. Conclusions: Fistulous empyema caused by common bacteria or Mycobacterium tuberculosis could be cured by surgical treatment and endobronchial intervention with adequate antimicrobial therapy, but fistulous empyema caused by non-tuberculous mycobacteria proved to be intractable. The challenge in the treatment of fistulous empyema due to non-tuberculous mycobacteria is the achievement of bacterial negativity.

Successful management of postoperative tracheal metastasis in small cell lung cancer with radiotherapy and durvalumab: A case report.

The patient in this report was a 73-year-old male who was diagnosed with small cell lung cancer (T3N0M0 stage IIB) after presenting with a 5.5 cm tumor detected in the right lower lobe of the lung by radiography. After right lower lobectomy and lymphadenectomy, postoperative adjuvant chemotherapy was administered with cisplatin and etoposide. At 27 months after surgery, the patient complained of wheezing. Tracheal metastasis was identified through computed tomography and bronchoscopy. Biopsy confirmed metastasis of small cell lung cancer. Radiotherapy (60 Gy) was administered to the mediastinal lymph nodes, including the supraclavicular region. The patient then underwent four cycles of carboplatin-etoposide-durvalumab, followed by durvalumab maintenance therapy. At 49 months after surgery, the patient complained of discomfort while speaking, leading to the discovery of a nodule in the subglottic space, which confirmed small cell lung cancer metastasis. Radiotherapy (30 Gy) was administered to the larynx and mediastinum, and the patient continued with durvalumab monotherapy. As of 61 months after surgery, he remains recurrence-free after the second course of radiotherapy. Our favorable outcome could be explained by the synergy between immunotherapy and radiotherapy. Here, we report a rare case of postoperative tracheal metastasis in small cell lung cancer successfully managed with radiotherapy and durvalumab. This shows promise in achieving local disease control and extending survival in postoperative metastatic lesions, highlighting a potential therapeutic approach.

An independent prognostic factor in surgical cases of pleural empyema caused by common bacteria is the presence of a fistula.

OBJECTIVES: Some surgical cases of pleural empyema lead to death despite multidisciplinary treatment. The purpose of this study was to identify prognostic factors in cases treated surgically for pneumonia-associated pleural effusions and empyema caused by common bacteria. METHODS: We conducted a retrospective cohort study of 108 surgical patients of empyema who encountered at our hospital between 2011 and 2021. Patients were divided into surviving and non-surviving cases. Factors on admission (age, sex, body mass index, presence of fistula, performance status, pleural fluid culture results, HbA1c, albumin, leukocytes, hemoglobin, body temperature, heart rate, respiratory rate, systolic blood pressure, prognostic nutritional index, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and RAPID score) were compared between the two groups. RESULTS: There were 87 cases of pleural empyema caused by pneumonia due to common bacteria. Variables that differed significantly in univariate analysis between the surviving and non-surviving cases in patients' characteristics on admission were fistula (p value < 0.001, odds ratio 20.000, 95% confidence interval 3.478-115.022), positive pleural fluid culture (0.016, 6.591, 1.190-36.502), body mass index < 18.5 (0.001, 16.857, 1.915-148.349), performance status 0-1 (0.007, 11.778, 1.349-102.858), and hemoglobin (0.024, 1.768, 1.077-2.904). Multivariate analysis showed significant differences in the presence of fistula (p = 0.036, CI 1.174-125.825). The odds ratio was 12.154. The mortality rate was 3.8% for non-fistulous empyema and 44.4% for fistulous empyema. In 6 of 9 cases of fistulous empyema, the fistula could be closed. CONCLUSION: Fistula was a significant independent prognostic factor for pneumonia-associated pleural effusions and empyema caused by common bacteria.

Right pneumothorax with congenital pericardial defect showed right atrium mimicking bulla in surgery.

BACKGROUND: Congenital pericardial defect (CPD) is found incidentally in cases of pneumothorax. CPD is seen in left side rather than right side and it is not generally known among thoracic surgeons how the inside of the pericardial space can be seen from the thoracic cavity in cases of pericardial defect. CASE PRESENTATION: A 52-year-old man with dyspnea was referred to our hospital because of the diagnosis of right pneumothorax. Chest radiography showed a right lung collapse and a pneumopericardium on the left side. Despite insertion of a chest tube, air leakage prolonged, bullectomy at the apex of the right lung was performed under thoracoscopy. During surgery, thoracoscope showed that the right atrium seemed as if it had been a non-pedunculated bulla or cardiac cyst. Heart beating, continuity with the heart, and the absence of respiratory motion could distinguish the right atrium from a bulla, and pericardial defect was confirmed. Preoperatively, the patient had no cardiac symptoms related to the CPD, and therefore, it was determined that a procedure to close the CPD was not necessary. Any complication and recurrence did not occur 6 months after surgery. CONCLUSIONS: Right pneumothorax with CPD showed right atrium mimicking bulla in surgery. It is important to consider correction of CPD if there are cardiac symptoms at the onset of pneumothorax, and not to misinterpret the right atrium as a bulla.

Partial anomalous pulmonary venous connection and a tracheal bronchus associated with lung cancer in the same lobe: classification of partial anomalous pulmonary venous connection in lung resection.

A 73-year-old man with primary lung adenocarcinoma (StageIA3), which was solid nodule in the posterior segment, was simultaneously diagnosed as having partial anomalous pulmonary venous connection (PAPVC) and a tracheal bronchus in the same lobe on preoperative chest computed tomography. Right upper lobectomy was performed as the definitive treatment for both the lung cancer and the PAPVC. The superior pulmonary vein connected to the proximal superior vena cava and the pulmonary artery to the apical segment diverged at the proximal portion of the right pulmonary artery trunk along with the tracheal bronchus. The patient's pulmonary arterial pressure improved after lobectomy. The patient is living well without recurrence of lung cancer 6 months after surgery. In conclusion, it is important to confirm the presence of anomalous pulmonary vein drainage to prevent the lethal change of pulmonary-systemic blood flow. Based on the classification of PAPVC proposed, surgical plan should be considered carefully.

Postpneumonectomy syndrome related to the thickness of the fat tissue in the anterior mediastinum: a retrospective observational study.

BACKGROUND: Postpneumonectomy syndrome (PPS) is a life-threatening condition characterized by the extrinsic compression of the mainstem bronchus after pneumonectomy, causing rapidly progressive dyspnea. Information regarding the predictive factors of this condition is limited. Thus, the current study aimed to identify the predictive findings that can help prepare the treatment of PPS in advance. METHODS: The present study is a retrospective observational study. We reviewed the medical records of 12 consecutive patients who underwent pneumonectomy for lung cancer or tuberculosis between 2009 and 2020. The anatomical findings evaluated via computed tomography scan, nutritional status assessed using laboratory data, respiratory function, intraoperative variables between PPS and non-postpneumonectomy-syndrome patients were compared. RESULTS: There were two female patients who presented with left PPS (PPS 1 and PPS 2 aged 73 and 55 years, respectively). The median age of 10 non-postpneumonectomy-syndrome patients (n=6, men and n=4 women) was 66 (range, 54-76 years). Four and six patients underwent right and left pneumonectomy, respectively. The fat tissue thickness in the anterior mediastinum was significantly thinner in PPS than in non-postpneumonectomy-syndrome patients. However, the body mass index (BMI) and other nutritional parameters did not differ between PPS and non-postpneumonectomy-syndrome patients. The median vital capacity was higher in PPS than in non-postpneumonectomy-syndrome patients. The decrement of respiratory function and body weight after pneumonectomy did not differ between two groups. The intraoperative variables did not also differ between two groups. CONCLUSIONS: The fat tissue in the anterior mediastinum between the bilateral lungs is an anchor that can help maintain the normal position of the mediastinum after pneumonectomy. Thus, the fat tissue thickness between the bilateral lungs can be a predictive factor for the occurrence of PPS before surgery.

[Acute Necrotizing Esophagitis Occurred after Lung Resection for Lung Cancer].

The patient was a 78-year-old man who had undergone left lung segmentectomy (S6) with lymph node dissection for lung adenocarcinoma. One year and 5 months later, lung partial resection was performed for the lung cancer recurrence and the hematemesis was noted on the next day of surgery. Upper gastrointestinal endoscopy revealed extensive black necrosis on the mucosa of the esophagus, which was diagnosed as acute necrotizing esophagitis. To treat the bleeding, the exposed esophageal vessels were clipped via endoscopy several times. The endoscopy on the 64th post-operative day showed the mucosa recovered and he could be discharged on the 85th day. The exact etiology of acute necrotizing esophagitis is unknown in most cases.

An entire clinical course of mediastinal myxofibrosarcoma treated by surgery and radiation.

A woman in her 70s with an 8.6-cm tumor in the anterior mediastinum underwent tumor excision by median sternotomy, which combined resection of the fifth and sixth ribs. The pathological diagnosis was myxofibrosarcoma, and pathologically curative resection was accomplished. Local recurrence was detected at 10, 19, 23 and 28 months after the initial surgery. After repeated surgical resection, radiation therapy for the fourth unresectable recurrence resulted in failure. She died 34 months after the initial surgery. There have been 3 case reports of mediastinal myxofibrosarcoma. With regard to prognosis, control over local recurrence by surgical resection might be essential to achieve a long survival. However, the clinical course of mediastinal myxofibrosarcoma has not been reported in detail. This is the first description on the entire clinical course of mediastinal myxofibrosarcoma.

A giant mediastinal liposarcoma weighing 3500g resected with clam shell approach, a case report with review of literature.

INTRODUCTION: Liposarcoma is rare in the mediastinum and is less than 1% of all mediastinal tumors. In the present report, we demonstrated our case and summarized the principal treatment of the mediastinal liposarcoma with literature review. PRESENTATION OF CASE: A 50-year-old man presented at our hospital with complain of dyspnea. Chest radiography showed remarkable cardiomegaly. Computed tomography revealed an anterior mediastinal tumor from the level of the cephalic vein to the diaphragm of bilateral thoracic cavity with fat component. Using clam shell approach, complete en bloc resection of the tumor was performed. The weight of the tumor was 3500g. The pathological findings were 0that size of adipocyte and lipoblast were different, and the nuclei of atypical stromal cell were misshapen. Immune-histologic examination was negative for MDM2 and cyclin-dependent kinase 4. The diagnosis was liposarcoma, well-differentiated type. He could discharge 10days after surgery. Without adjuvant therapy, disease free survival for three years has passed. DISCUSSION: From 1990-2016 in Japan, 60 cases of the mediastinal liposarcoma were reported. In analysis of the 61 cases including the present case, adjuvant therapy was performed in 14 cases, subsequently, and recurrence was recognized in 5 cases. Adjuvant therapy did not significantly suppress the recurrence. CONCLUSION: Mediastinal liposarcoma weighing 3500g could be resected using calm shell approach, and no recurrence interval for 3 years has been achieved without adjuvant therapy. Complete resection is the only means to achieve the favorable outcome in mediastinal liposarcoma.

[Psoriasis and Psoriatic Arthritis Induced by Nivolumab in a Patient with Advanced Non-Small-Cell Lung Cancer].

BACKGROUND: Immune checkpoint-blocking antibodies may induce specific side effects known as immune-relatedad verse events. CASE PRESENTATION: A 66-year-oldman without any history of autoimmune disease was referredto our hospital for treatment of lung cancer in the right upper lobe. The tumor was diagnosed as Stage III A non-small-cell lung cancer by using bronchoscopic biopsy, computedtomography, andFDG -PET. After a single course of cisplatin andpemetrexed , the tumor size increasedremarkably andthe regimen was changedto nivolumab(3mg/kg every 2 weeks). Psoriasis andpsoriatic arthritis were observed after 4 courses of nivolumab. Nivolumab treatment continued, and the oral administration of predni- solone(20mg/day)couldimprove psoriasis andpsoriatic arthritis. However, the lung cancer showedprogressive disease after the 11th course of nivolumab. CONCLUSION: Psoriasis andpsoriatic arthritis were inducedby nivolumab in the patient without any history of autoimmune disease. It is unclear how prednisolone affected nivolumab for the treatment of lung cancer.

The first rib hypoplasia and the aberrant pulmonary artery branch detected by three-dimensional computed tomography in a surgical case with apical lung cancer, a case report.

BACKGROUND: The complete resection is one of the most crucial requirements to achieve favorable outcomes in oncologic surgery. The apex of the lung is surrounded complicatedly by the clavicle, the first rib, the subclavian artery and vein, and the brachial plexus. Therefore, the image information especially about the infiltration of adjacent anatomic structures, facilitates the surgery in the apical lung cancer. CASE PRESENTATION: A 70-year-old man presented at our hospital with a computed tomography (CT) scan showing a tumor at the left lung apex that infiltrated the chest wall. Two anatomical anomalies were found, which were the first rib hypoplasia and the aberrant pulmonary artery branch. The three-dimensional (3D) CT enhanced with using bolus tracking method, simultaneously revealed that the subclavian vessels existed between the clavicle and the second rib, and the left lingual pulmonary artery and the ventrobasal pulmonary artery diverged from the left main pulmonary artery as the first branch. We diagnosed the tumor as a primary lung squamous cell carcinoma that infiltrated the second rib, because sputum cytology suggested squamous cell carcinoma. Left lung upper lobectomy with lymph node dissection and chest wall resection (the second and third ribs) were performed with caution for the anatomical anomalies. The pathological diagnosis was pleomorphic carcinoma (5.0 × 3.0 × 1.9 cm) that invaded the second costal bone, and the pathological stage was confirmed to be pT3N0M0. Pathologically curative resection was accomplished. The patient was discharged from the hospital on 10 days after surgery. CONCLUSION: The 3D-CT precisely detected the anomalous structure consisted with the clavicle, the second rib, the subclavian artery and vein, the aberrant pulmonary artery branch. In the present case with the apical lung cancer, the evaluation of the anatomical structure via 3D-CT facilitated to achieve a pathological complete resection.

[Complete Remission after Weekly Intravenous Nanoparticle Albumin-Bound Paclitaxel in Elderly Patients with Non-Small-Cell Lung Cancer].

Case 1: An 86-year-old man was diagnosed with large cell or squamous cell lung cancer of clinical Stage II A.He was administered nanoparticle albumin-bound paclitaxel(nab-PTX)as fourth-line chemotherapy after monochemotherapy with docetaxel, vinorelbine, and S-1.The patient continues to show complete remission at the 15 courses of nab-PTX.Case 2: A 79-year-old man underwent partial resection of the right lower lung, and the pathological diagnosis was large cell lung cancer of pStage I A.However, recurrence in the right lung and multiple lymph node metastases were identified 3 years after the surgery.He was administered nab-PTX as second-line chemotherapy after vinorelbine monotherapy, and he has shown complete remission for a year.Weekly intravenous nab-PTX may be useful in elderly patients with non-small-cell lung cancer.

Cilostazol strengthens the endothelial barrier of postcapillary venules from the rat mesentery in situ.

OBJECTIVE: Although cilostazol, a phosphodiesterase 3 inhibitor, has been suggested to strengthen the endothelial barrier using cultured endothelial monolayers, its effect has not been tested in vivo. We, therefore, investigated effects of cilostazol on barrier properties of postcapillary venules of the rat in situ. METHODS: Cilostazol was administered to the rats through oral gavage at 4 hours before the measurements. The hydraulic permeability (L(p)) and the effective osmotic pressure (σΔπ), molecular sieving properties of microvascular walls, were estimated in single mesenteric postcapillary venules by a micro-occlusion technique, first during control perfusion and then in the presence of histamine. RESULTS: When the vessels were inflamed with histamine, cilostazol attenuated a transient increase in L(p) and prevented σΔπ from falling. Furthermore, it reduced baseline L(p) under a control state. CONCLUSION: Cilostazol appears to tighten the endothelial barrier in situ, at least in part by inhibiting the cAMP-degrading enzyme in the endothelium.

[Foreign body granuloma with positive 18-fluorodeoxyglucose positoron emission tomography( FDGPET)3 years after thymectomy].

A seventies year-old woman underwent thymo-thymectomy through a median sternotomy for type B2 thymoma. Annual screening with fluorodeoxyglucose positron emission tomography (FDG-PET) and computed tomography( CT) did not show any abnormality until 3 years after surgery, when a FDG-positive lesion, 1.5 cm in diameter, was found in the top of the anterior mediastinum. The lesion was resected under the diagnosis of thymoma recurrence, but was pathologically diagnosed as a foreign body granuloma including a suture thread. False-positive results with FDG-PET are related to FDG-uptake by inflammatory cells (e.g. macrophages and lymphocytes in the granuloma). Although FDG-PET is useful for diagnosing the postoperative recurrence of tumors, it should be noted that a foreign body granuloma and local recurrence of tumor have similar growth rates and both appear positive on FDGPET.

Ritodrine for intractable uterine pain due to extrapelvic malignant tumor metastases: a case report.

BACKGROUND: Effective pain management is an essential component of cancer treatment as approximately 75% of all cancer patients experience excruciating nociceptive pain even at maximum safe doses of nonsteroidal anti-inflammatory drugs and/or opioids. We report a case where ritodrine hydrochloride effectively controlled refractory pain due to uterine metastases from thymic carcinoma. CASE PRESENTATION: A 40-year-old woman presented at our hospital with chest discomfort, severe right femoral pain, and intermittent hypogastralgia. Computed tomography, magnetic resonance imaging, and positron emission tomography revealed a large mass in the anterior mediastinum, multiple nodules in the lungs, and multiple metastases on the uterus, lumbar vertebrae, and pelvic bones. Needle biopsies of the mediastinal and uterine cervical tumors revealed undifferentiated carcinoma of the thymus metastasizing to the uterus. Oxycodone and nonsteroidal anti-inflammatory drugs relieved the right femoral pain but not the hypogastralgia. We speculated that hypogastralgia did not result from somatalgia but from splanchnodynia. Ritodrine was administered in an effort to inhibit uterine contractions and to reduced the refractory pain and improved her quality of life. CONCLUSION: Ritodrine relieved the pain caused by uterine contraction due to metastases and enhanced the quality of life.

Surgery for lung adenocarcinoma with smokers' polycythemia: a case report.

BACKGROUND: Smoking is a cause of cancer and polycythemia. Therefore, surgeons who treat patients with cancer may also encounter patients with polycythemia. However, few cases of surgical patients with polycythemia have been reported; in particular, a surgical case involving smokers' polycythemia has never been reported. We herein report a patient with lung cancer and smokers' polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period. CASE PRESENTATION: A 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. A ground glass opacity had been identified in the upper lobe of the right lung and was gradually enlarging. In March 2012, bronchoscopic cytology for investigation of the mass revealed non-small cell lung cancer, suggesting primary lung non-small cell carcinoma (T1bN0M0, Stage IA). When he was referred to our hospital for surgery, his complete blood count showed a red blood cell level of 6.50×106/µL, hemoglobin of 21.0 g/dL, and hematocrit of 60.1%. The hematologists' diagnosis was secondary polycythemia due to heavy smoking (smokers' polycythemia) because the white blood cell and platelet counts were within normal limits and the erythropoietin was not increased. We calculated the appropriate phlebotomy and infusion volumes based on a formula that we modified. After 550 g of blood was phlebotomized to reduce the hematocrit to approximately 55%, video-assisted right lung upper lobectomy with lymph node dissection was performed in April 2012. The hematocrit was maintained at <50% postoperatively, and the patient was uneventfully discharged on postoperative day 7. The predictive hematocrit and measured hematocrit were very closely approximated in this case. CONCLUSION: We experienced a patient with smokers' polycythemia who underwent right upper lobectomy for adenocarcinoma. The findings in this case report are meaningful for surgeons treating cancer patients because there are few reports discussing the perioperative care of surgical patients with polycythemia.

Skin rash by gefitinib is a sign of favorable outcomes for patients of advanced lung adenocarcinoma in Japanese patients.

Skin rash is one of the notorious adverse events of gefitinib as well as other epidermal growth factor receptor tyrosine kinase inhibitors. The differences of response rate and frequency of adverse events between ethnic groups are well known. Some reports demonstrated the correlation between development of rash and efficacy in Caucasian patients treated with erlotinib, gefitinib or cetuximab. We analyzed clinical course of Japanese patients of lung adenocarcinoma in order to assess the relation between adverse events and efficacy of gefitinib. Between January 2008 and June 2012, 24 Japanese patients administered gefitinib 250 mg daily. The adverse events were evaluated in accordance with Common Terminology Criteria For Adverse Events v4.0 (CTCAE). Objective response to gefitinib was evaluated with using computed tomography every 1-2 months. The relationship between each adverse event and objective response was examined by chi-square test. The Log-rank Test was used to assess the relationship between the presence of skin rash and overall survival. Twenty four patients with a median age of 67 years (range 55-89) entered were 16 female and 8 male patients; the pathological diagnosis of all patients was adenocarcinoma. Skin rash in CTCAE occurred in 10. The objective response and overall survival among the patients with skin rash was significantly superior to the patients without skin rash. Skin rash by gefitinib correlates with improved clinical outcomes among advanced lung adenocarcinoma patients.

Gefitinib frequently induces liver damage in patients with lung adenocarcinoma previously treated by chemotherapy.

BACKGROUND: Gefitinib is known as one of the agents for treating patients with both advanced lung cancer and an epidermal growth-factor receptor mutation. In the epidermal growth-factor receptor-mutant advanced non-small-cell lung cancer population, gefitinib therapy has been associated with increased response rate, longer progression-free survival, and better quality of life compared to other anticancer drugs. However, gefitinib has to be discontinued for patients in whom adverse events occur, even if it is still effective. Here, we retrospectively assessed the clinical course of patients receiving gefitinib therapy, with a particular focus on liver damage. PATIENTS AND METHODS: Of 24 Asian patients treated with 250 mg gefitinib daily at Kanagawa National Hospital, Japan, between January 2008 and June 2012, grade 3 liver damage (Common Terminology Criteria for Adverse Events, version 4.0) occurred in nine and were eligible for our assessment. The regimen was subsequently changed to alternate-day administration. The relationships between liver damage and each clinical factor were retrospectively examined using Fisher's exact test. RESULTS: Of the nine patients with liver damage, seven had previous exposure to another anticancer drug. There was a significant relationship between the incidence of liver damage and previous chemotherapy (P = 0.009). The objective response rates of patients treated with daily gefitinib 250 mg and alternate-day gefitinib following liver damage were 66.7% and 46.7%, respectively; these were not significantly different (P = 0.597). CONCLUSION: Gefitinib for advanced adenocarcinoma patients who have previously undergone chemotherapy should be used cautiously and liver function monitored closely, because it frequently induces significant liver damage. The alternate-day administration of gefitinib may be a suitable option for patients in whom daily gefitinib therapy induces liver damage.

Innovative segmentectomy to remove the posterior segment of the lower lobe (S¹°) of the lung.

We describe our innovative technique for performing segmentectomy of the posterior segment of the lower lobe of the lung, being segment number 10 (S¹°). In segmentectomy of S¹°, it is difficult to identify A¹° from the interlobar fissure because the pulmonary artery to S¹° (A¹°) branches from A(9+10) and runs dorsally and deeply into the lung tissue. Moreover, to reach S¹° from the interlobar fissure, the lung tissue should be cut between S6 and S8, because S¹° is not located beside the interlobar fissure. However, it is difficult to identify the boundary between the S6 and S8 without a route marker. To solve these difficulties, we divided S6 and S¹° from each other at the beginning of the procedure, which enabled A¹° to be identified easily from the dorsal side. Because S6 and S(8-10) should be divided in S¹° segmentectomy at the end, the division between S6 and S(8-10) at the beginning of procedure is not only reasonable, but makes the procedure simple.