Thymic MALT lymphoma associated with Sjögren's syndrome with postoperative cardiac tamponade and acute pleuritis: a case report.

BACKGROUND: Thymic mucosa-associated lymphoid tissue (MALT) lymphoma is rare and is known to be associated with Sjögren's syndrome (SjS). SjS is rarely accompanied by serositis. Here, we describe the first case of postoperative cardiac tamponade and acute pleuritis in a patient with thymic MALT lymphoma associated with SjS. CASE PRESENTATION: A 33-year-old woman with SjS presented with an anterior mediastinal mass on chest computed tomography, which was performed for further examination of the condition. Suspecting a thymic MALT lymphoma or thymic epithelial tumor, total thymectomy was performed. The mediastinal mass was histopathologically diagnosed as a thymic MALT lymphoma. The patient was discharged with a good postoperative course but visited the hospital 30 days after surgery for dyspnea. Cardiac tamponade was observed and drainage was performed. Four days after pericardial drainage, chest radiography revealed massive left pleural effusion, and thoracic drainage was performed. The patient was diagnosed with serositis associated with SjS and treated with methylprednisolone, which relieved cardiac tamponade and pleuritis. CONCLUSIONS: Surgical invasion of thymic MALT lymphomas associated with SjS may cause serositis. Postoperative follow-up should be conducted, considering the possibility of cardiac tamponade or acute pleuritis due to serositis as postoperative complications.

Risk factors for the recurrence of primary spontaneous pneumothorax after video-assisted thoracoscopic surgery in patients younger than 40 years.

Background: Video-assisted thoracoscopic surgery (VATS) is a standard primary spontaneous pneumothorax (PSP) procedure. However, its high recurrence rate compared to open thoracotomy is a problem. Therefore, various methods to prevent recurrence have been developed. The present study investigated the risk factors for postoperative recurrence of PSP after VATS. Methods: From January 2008 to November 2022, 207 patients younger than 40 years of age without underlying pulmonary disease underwent thoracoscopic bullectomy for PSP. Among them, 96 underwent staple line reinforcement with a polyglycolic acid (PGA) sheet and autologous blood spraying. Patient characteristics and surgical outcomes were analyzed to determine the prognostic factors for postoperative recurrence. Results: Twenty-seven patients (13.0%) experienced recurrences. A multivariate analysis using Cox regression analysis revealed that age younger than 20 years [P=0.039; hazard ratio (HR) =2.337; 95% confidence interval (CI): 3.283-17.287], history of contralateral pneumothorax (P<0.001; HR =7.533; 95% CI, 1.486-12.336), and no staple line reinforcement (P=0.007; HR =4.282; 95% CI, 1.043-5.236) were risk factors for recurrence after pneumothorax surgery. Conclusions: Age younger than 20 years and history of contralateral pneumothorax were risk factors for postoperative recurrence of pneumothorax. Staple line reinforcement with a PGA sheet and spraying of autologous blood reduced the postoperative recurrence rate of PSP.

Prognostic Impact of Visceral Pleural Invasion in Resected Solitary Lung Metastases from Gastric Cancer.

PURPOSE: Pulmonary resection of metastases from gastric cancer is extremely rare because gastric cancer metastasis to the lungs or thoracic cavity occurs as multiple pulmonary metastases, carcinomatous lymphangitis, or carcinomatous pleurisy. Therefore, the significance of surgery for pulmonary metastasis of gastric cancer remains unclear. This study aimed to investigate the surgical outcomes and prognostic factors for survival after the resection of pulmonary metastases from gastric cancer. METHODS: From 2007 to 2019, 13 patients with pulmonary metastasis of gastric cancer underwent metastasectomy. Surgical outcomes were analyzed to determine the prognostic factors for recurrence and overall survival (OS). RESULTS: All the patients underwent pulmonary resection for solitary metastases. At the median follow-up time of 45.6 months (range, 4.8-106.8 months), five patients experienced a recurrence of gastric cancer after metastasectomy. The 5-year recurrence-free survival rate was 44.4%, and the 5-year OS rate after pulmonary resection was 45.3%. Univariate analysis revealed that visceral pleural invasion (VPI) was an unfavorable prognostic factor for both recurrence-free and OS. CONCLUSION: Pulmonary resection of solitary metastases from gastric cancer may be an effective therapeutic option to improve survival. VPI in gastric cancer metastasis is a negative prognostic factor.

[Right S3+4+5 Resection for Lung Cancer with Displaced B3].

A 68-year-old man was referred to our hospital due to an abnormal shadow on chest X-ray film. Chest computed tomography showed a tumor in the right middle lobe. The tumor was 41 mm in size and invaded S3. Preoperative bronchoscopy revealed that right B1, B2, and B3 were branched independently, and B3 was branched from the middle lobe bronchus. A trans-bronchial biopsy was performed and primary lung squamous cell carcinoma was diagnosed (cT2bN0M0, stageⅡA). Although minor fissure was not observed, S3+4+5 resection was performed successfully by dividing pulmonary blood vessels and bronchus before dividing incomplete lobulation (bronchus-first method). The bronchus-first method is useful to avoid not only post-operative air leakage but also accidental cutting of the displaced bronchus by dividing incomplete lobulation frequently associated with bronchial branching abnormalities.

Bronchial Sleeve Resection and Double-Barreled Reconstruction for a Carcinoid Tumor.

Sleeve resection and double-barreled reconstruction are very rarely adopted for peripheral bronchial tumors. This surgical procedure was used for a carcinoid tumor in the bifurcation of the left upper and lower lobe bronchi. Bronchoplasty was accomplished by suturing the upper and basal bronchi together and anastomosing them to the left main bronchus. The techniques for double-barreled reconstruction described in this report obtained a successful result. These manipulations may be applicable to resection of other bronchial and tracheal bifurcations.

[Early VATS(Video-Assisted Thoracoscopic Surgery)Was Effective for a Case of Chylothorax after Lung Cancer Excision].

A 66-year-old man underwent a right upper lobectomy and lymph node dissection for lung cancer. We confirmed a milky white pleural effusion after diet initiation on the first postoperative day, and a chylothorax was diagnosed. The patient began a f at-restricted diet; however, the pleural effusion did not decrease. Therefore, we performed VATS(video-assisted thoracoscopic surgery)1 week after surgery with good results. Early VATS for a postoperative chylothorax was useful.

Successful treatment of refractory chylothorax by pedicled omentoplasty.

A 52-year-old female with a history of past surgery for arteriovenous malformation of the thoracic spinal cord presented with left chylothorax. Lymphangiography identified diffuse lymphatic vessel (LV) growth with ectasia at the left supradiaphragmatic level. On the right side, the LVs were absent due to previous surgery. Given the ineffectiveness of conservative management, the patient required surgery. Thoracotomy showed extensive pleural fibrosis, lung atelectasis, and diffuse chyle defluxion on the parietal pleura. The diffuse chyle defluxion was not resolved by ligation. Therefore, we performed pedicled omentoplasty to fill the pleural space and to utilize its drainage and angiogenic capacity. Two years after the procedure, there was no sign of relapse. There are very few reports of refractory chylothorax successfully treated by pedicled omentoplasty. The procedure would be useful for the treatment of chylothorax when non-surgical or typical surgical management fails.

Vascular-type Ehlers-Danlos syndrome caused by a hitherto unknown genetic mutation: a case report.

INTRODUCTION: Vascular-type Ehlers-Danlos syndrome is an autosomal dominant disease that causes arterial spurting, intestinal perforation, uterine rupture and hemopneumothorax due to decreased production of type III collagen. The average age at death is 48 years old, and it is considered to be the most severe form of Ehlers-Danlos syndrome. We report the case of a 64-year-old Japanese woman and her 38-year-old daughter who were diagnosed with this disease. CASE PRESENTATION: A 64-year-old Japanese woman was referred to our hospital because of right anterior chest pain following cough and pharyngeal discomfort. Pleurisy was suspected due to the presence of right pleural effusion, so the next day she was referred to our department, where a detailed examination led to the diagnosis of hemothorax. The bleeding that caused the right hemothorax was difficult to control, so our patient was transferred to the Department of Thoracic Surgery for hemostasis control. Our patient's personal history of uterine hemorrhage and skin ulcers, as well as the finding of skin fragility during surgery, were indicative of a weak connective tissue disease; therefore, after improvement of the hemothorax, a genetic analysis was performed. This revealed a heterozygous missense mutation in COL3A1, c.2411 G>T p.Gly804Val (exon 36). A detailed investigation conducted at a later date revealed that her daughter also had the same genetic mutation. This led to the diagnosis of vascular-type Ehlers-Danlos syndrome characterized by a new gene mutation. CONCLUSION: We report a new genetic mutation associated with vascular-type Ehlers-Danlos syndrome. We present the clinical and imaging findings, and the disease and treatment course in this patient. We believe this information will be important in treating future cases of vascular-type Ehlers-Danlos syndrome in patients with this mutation.

[Vascular-type Ehlers-Danlos syndrome incidentally diagnosed at surgical treatment for hemothorax; report of a case].

Vascular-type Ehlers-Danlos syndrome(vEDS) is a rare autosomal dominant inherited disorder of the connective tissue, which often causes arterial ruptures and surgical complications. We report the case of a vEDS patient who was incidentally diagnosed at surgical treatment for hemothorax. A 64-year-old woman with a past history of hysterectomy due to excessive bleeding during childbirth visited our hospital complaining of chest pain. Chest computed tomography revealed right pleural effusion suspected of hemothorax and a high density area behind the right anterior chest wall. Emergency thoracoscopy revealed bloody spots throughout the mediastinal pleura, suggestive of bleeding from the right internal thoracic artery. During thoracoscopy, easy bruising of the tissue by surgical manipulation was noted which led us to suspect connective tissue disease. A biochemical analysis by cultured dermal fibroblasts and molecular biological examination established the diagnosis of vEDS.

Minute pulmonary meningothelial-like nodules coexisting with pulmonary cryptococcosis mimicking lung cancer.

A 68-year-old woman was found to have an abnormal shadow on chest X-ray. Computed tomography showed some small ground-glass opacities in the bilateral lung field and also a 22-mm tumor in the left lower lobe, which showed high accumulation on (18)F fluorodeoxyglucose positron emission tomography. Each of them was difficult to distinguish from lung cancer clinically. Preoperative localization of a small ground-glass opacity nodule with computed tomography-guided lipiodol marking and resection of each using a fluoroscopic unit was performed. Pathological findings from the small nodule showed minute pulmonary meningothelial-like nodule, and those from the tumor and fungal culture showed pulmonary cryptococcosis. To the best of our knowledge, this is the first reported case of coexisting minute pulmonary meningothelial-like nodules and pulmonary cryptococcosis mimicking lung cancer. Thoracoscopy assisted by computed tomography-guided lipiodol marking enabled us to diagnose them.

[Mediastinal lymph node carcinoma of unknown primary site; report of a case].

A 71-year-old woman was admitted to our hospital because of a mediastinal mass. Chest computed tomography (CT) and fluorodeoxyglucose-positron emission tomography (FDG-PET) showed only 1 swollen mediastinal lymph node. Serum levels of carcinoembryonic antigen (CEA) were found to be elevated. Preoperative examination did not detect the primary lesion. A mediastinal lymphadenectomy was performed, and histologically, the tumor demonstrated poorly differentiated adenocarcinoma. Immunohistochemical staining for cytokine( CK) 7 and thyroid transcription factor( TTF) -1 were positive but were negative for CK20, suggesting a pulmonary origin. During 2-years postoperative follow-up, no signs of primary site growth can be detected. Surgical resection of mediastinal lymph node carcinoma of unknown primary site has the possibility of a good prognosis.

High serum immunoglobulin G4-related retrosternal fibrosclerosis.

A 65-year-old man with a history of exposure to asbestos complained of left leg edema. Computed tomography showed a flat, symmetrical, and longitudinal retrosternal thickening in addition to a presacral tumor. Retroperitoneal fibrosis was suspected. Serum immunoglobulin G4 (IgG4) levels were elevated (213 mg/dL). Thoracoscopic biopsy was performed. Histopathologic findings showed fibrotic tissue accompanied by proliferation of IgG4-positive plasma cells (proportion of IgG4/IgG-positive plasma cells ≥70%) indicative of multifocal fibrosclerosis.

Cricopharyngeal myotomy for primary cricopharyngeal dysfunction caused by a structural abnormality localized in the cricopharyngeus muscle: report of a case.

Primary cricopharyngeal dysfunction (PCD) is a rare idiopathic disorder of the upper esophageal sphincter (UES), characterized by oropharyngeal dysphagia, frequent aspiration, and narrowing at the level of the UES. Cricopharyngeal myotomy (CPM) has been used to treat oropharyngeal dysphagia of different causes including anatomic, neuromuscular, iatrogenic, inflammatory, neoplastic, and idiopathic; however, the indications for CPM and predictors of its outcome are not clearly defined. We report a case of PCD with hypertonic UES caused by a structural abnormality localized in the cricopharyngeus muscle, visualized as a cricopharyngeal bar, which we treated successfully by CPM, achieving long-term relief.

[Diaphragmatic hernia complicated with perforated stomach during pregnancy].

Diaphragmatic hernia complicating pregnancy is rare and results in a high mortality rate, if early surgical intervention is not undertaken. We report a case of a woman at 32 week's gestation who was admitted to our hospital due to severe epigastralgia. Diaphragmatic relaxation had been pointed out since her birth. The patient was initially diagnosed with acute gastritis, but she developed acute respiratory insufficiency on day 3 of hospitalization. Chest X-ray and computed tomography showed niveau in the left pleural cavity. She was treated with chest tube drainage and an emergency caesarean was performed. The next day, gastric fiberscope demonstrated perforation of gastric ulcer in the left hemithorax. She was diagnosed as having diaphragmatic hernia complicated by a perforated stomach. Emergency thoracotomy was carried out and primary repair of both stomach and diaphragma was performed.

[Lung abscess which needed to be distinguished from lung cancer; report of a case].

BACKGROUND: Differential diagnosis of lung abscess from lung cancer is sometimes difficult. CASE: In February 2009, a 57-year-old man consulted our hospital complaining of bloody sputum. Chest computed tomography (CT) demonstrated a 2.5 cm nodule with pleural indentation, spicula and vascular involvement in the right S(3). Bronchofiberscope could not establish a definitive diagnosis. Blood test showed no abnormality. Three months later, progression of the nodule to the adjacent middle lobe was demonstrated by follow-up CT, and F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) showed isotope accumulation in the nodule and hilar lymph node. A diagnosis of lung cancer was suspected and surgery was performed. The diagnosis of possible lung cancer was made by needle biopsy, and the patient underwent right upper lobectomy and partial resection of middle lobe with standard nodal dissection. The final pathological diagnosis was lung abscess. CONCLUSION: Lung abscess must be kept in mind as a possible differential diagnosis when abnormal shadow suspected of lung cancer is observed.

Hemorrhagic shock resuscitation with an artificial oxygen carrier, hemoglobin vesicle, maintains intestinal perfusion and suppresses the increase in plasma tumor necrosis factor-alpha.

It is known that damage to the intestinal mucosa followed by systemic inflammatory response is one of the leading causes of shock related morbidity and mortality. In this study, we examined the ability of an artificial oxygen carrier hemoglobin vesicle (HbV) to sustain systemic and intestinal perfusion during hemorrhagic shock. In rabbits, hemorrhagic shock (40% of the estimated blood volume) was resuscitated with 5% albumin (alb group), HbV suspended in 5% albumin (HbValb group), or washed red blood cells suspended in 5% albumin (RBCalb group). Plasma tumor necrosis factor (TNF)-alpha level was measured in rats under the same experimental protocol. No significant intergroup differences were seen in systemic hemodynamics. In contrast, parameters of intestinal perfusion significantly deteriorated in the alb group but were equally well sustained in the HbValb and RBCalb groups. Also, a significant increase in plasma TNF-alpha level was seen in the alb group but not in the RBCalb or HbValb groups. These results indicate the proficient oxygen transporting capability of HbV and its potential efficacy in shock resuscitation.