Combined resection of lung cancer and thoracic aortic wall with simultaneous thoracic aortic endografting: a case report.

BACKGROUND: Combined resection of lung cancer and the thoracic aortic wall with thoracic aortic endografting has been reported. However, whether the resection and endografting should be performed simultaneously or in two steps remains controversial. CASE PRESENTATION: A 68-year-old man was referred to our hospital because of left chest pain. Chest contrast-enhanced computed tomography revealed a huge tumor of the left lower lung lobe, and invasion to the aortic wall was suspected. Bronchoscopic examination was performed, revealing squamous cell carcinoma with a programmed death ligand 1 expression level of 90%. The clinical stage was T4N0M0 stage 3A. After neoadjuvant chemotherapy and radiotherapy, we performed one-stage surgery with the patient in the right lateral decubitus position and the left inguinal region exposed for femoral vessel isolation. Posterolateral thoracotomy was performed with making a latissimus dorsi muscle flap. The pulmonary artery, vein, and left lower bronchus were cut with a stapler. After hilar isolation, we evaluated the involvement of the descending aorta and marked the area of the involved aortic wall by a surgical clip. Using the left femoral artery approach, a GORE TAG conformable thoracic stent graft was delivered to the descending aorta. After thoracic aortic endografting, the involved aortic wall was resected and the left lower lobe of the lung and resected aortic wall were resected en bloc. The adventitial defect was covered by the latissimus dorsi muscle flap. The operating time was 474 min, and the blood loss volume was 330 mL. The postoperative pathological diagnosis was adenocarcinoma with an epidermal growth factor receptor mutation of exon 19 deletion. The residual viable tumor was 7 mm in diameter and close to the resected aortic wall. The patient's postoperative course was uneventful. Five days after surgery, chest contrast-enhanced computed tomography revealed no endoleak or stent migration. Three months after surgery, he was alive with neither recurrence nor stent graft-related complications. CONCLUSIONS: One-stage surgery involving combined resection of lung cancer and the thoracic aortic wall with simultaneous thoracic aortic endografting in the right lateral decubitus position with the left inguinal region exposed is safe and acceptable.

Microscopic thymoma with a thymic cyst that enlarged over a 2-year period.

An 81-year-old woman was referred to our hospital because of right lung cancer. She underwent right upper lobectomy. Pathological examination revealed stage 1A adenocarcinoma. Four months postoperatively, chest computed tomography showed a small nodule with a diameter of 6 mm at the anterior mediastinum. After 2 years, the nodule had increased to 13 mm. To confirm the diagnosis and treat the mediastinal tumor, we resected the tumor and surrounding thymic tissue by a left robotic thoracic approach, considering the adhesion in the right thoracic cavity after right pulmonary resection. The operating time was 43 min. The patient had a favorable postoperative course and was discharged 3 days after surgery. Pathological examination revealed microscopic thymoma with a diameter of 400 µm very close to a thymic cyst. Microscopic thymoma can occur around a thymic cyst without myasthenia gravis, and the thymic tissue around the anterior mediastinal cyst should be resected.

Double polytetrafluoroethylene patch repair for diaphragmatic defect caused by diaphragmatic rupture following diaphragmatic resection with endostapler.

A 41-year-old man developed phrenic nerve palsy after the resection of anterior mediastinal tumor, who underwent diaphragmatic resection with an endostapler. After the surgery, the surgical stump ruptured, resulting in a large diaphragmatic defect with the liver prolapsing into the thoracic cavity. Then, the diaphragmatic defect was closed with a polytetrafluoroethylene (PTFE) patch. The diaphragm was reconstructed using a second PTFE patch overlaying the diaphragmatic defect that had been closed by the first PTFE patch, because solely patching the diaphragmatic defect had a risk of recurrence of diaphragmatic elevation due to remaining original diaphragm and the presence of phrenic nerve palsy. The second PTFE patch was fixed to the lower ribs by non-absorbable suture. The postoperative course was favorable. After 3 months, his symptoms and pulmonary function improved. We underwent double PTFE patch repair in a patient with both huge diaphragmatic defect and phrenic nerve palsy.

Successful use of left ventricular support device (Impella 5.0) and extracorporeal membrane oxygenation (ECMO) for postoperative cardiac arrest after lung cancer surgery: a case report.

Postoperative hemodynamic support with an Impella 5.0 was effective in a man who underwent lung lobectomy for lung cancer and cardiogenic shock. A 75-year-old man presented to hospital with an abnormal chest shadow on radiography. After thorough examination, the patient was diagnosed with lung cancer, and left lower lobectomy was performed. On the 2nd postoperative day, the patient experienced cardiac arrest because of a sudden drop in saturation of percutaneous oxygen. After a third defibrillation, his heartbeat resumed, and he was intubated and placed on a ventilator. Coronary angiography revealed acute coronary syndrome and the patient fell into a state of shock, which required venoarterial extracorporeal membrane oxygenation (VA-ECMO) support. Nevertheless, the circulatory dynamics are unstable, and Impella 5.0 was introduced. VA-ECMO and the Impella 5.0 were discontinued on the 6th and 8th postoperative days, respectively. The patient was eventually transferred to a nearby facility for further rehabilitation 109 days later.

An investigation of the internal morphology of asbestos ferruginous bodies: constraining their role in the onset of malignant mesothelioma.

BACKGROUND: Asbestos is a fibrous mineral that was widely used in the past. However, asbestos inhalation is associated with an aggressive type of cancer known as malignant mesothelioma (MM). After inhalation, an iron-rich coat forms around the asbestos fibres, together the coat and fibre are termed an "asbestos ferruginous body" (AFB). AFBs are the main features associated with asbestos-induced MM. Whilst several studies have investigated the external morphology of AFBs, none have characterised the internal morphology. Here, cross-sections of multiple AFBs from two smokers and two non-smokers are compared to investigate the effects of smoking on the onset and growth of AFBs. Morphological and chemical observations of AFBs were undertaken by transmission electron microscopy, energy dispersive x-ray spectroscopy and selected area diffraction. RESULTS: The AFBs of all patients were composed of concentric layers of 2-line or 6-line ferrihydrite, with small spherical features being observed on the outside of the AFBs and within the cross-sections. The spherical components are of a similar size to Fe-rich inclusions found within macrophages from mice injected with asbestos fibres in a previous study. As such, the spherical components composing the AFBs may result from the deposition of Fe-rich inclusions during frustrated phagocytosis. The AFBs were also variable in terms of their Fe, P and Ca abundances, with some layers recording higher Fe concentrations (dense layers), whilst others lower Fe concentrations (porous layers). Furthermore, smokers were found to have smaller and overall denser AFBs than non-smokers. CONCLUSIONS: The AFBs of smokers and non-smokers show differences in their morphology, indicating they grew in lung environments that experienced disparate conditions. Both the asbestos fibres of smokers and non-smokers were likely subjected to frustrated phagocytosis and accreted mucopolysaccharides, resulting in Fe accumulation and AFB formation. However, smokers' AFBs experienced a more uniform Fe-supply within the lung environment compared to non-smokers, likely due to Fe complexation from cigarette smoke, yielding denser, smaller and more Fe-rich AFBs. Moreover, the lack of any non-ferrihydrite Fe phases in the AFBs may indicate that the ferritin shell was intact, and that ROS may not be the main driver for the onset of MM.

Effects of tumor-infiltrating CD8+ T cells, PD1/PD-L1 axis, and expression patterns of HLA class I on the prognosis of patients with malignant pleural mesothelioma who underwent extra-pleural pneumonectomy.

Programmed cell death protein-1 (PD1), PD1 ligand 1 (PD-L1), and human leukocyte antigen (HLA) class I molecule play pivotal roles in T cell-induced anti-tumor immunity; however, the clinical impact of these parameters in resected malignant pleural mesothelioma (MPM) cases is unknown. We immunohistochemically evaluated the tumor infiltrated lymphocytes (TILs), PD1/PD-L1 axis, and expression of HLA class I in resected specimens from 58 patients with MPM who underwent extra-pleural pneumonectomy (EPP). Higher infiltration of CD3-TIL, CD8-TIL, and PD1-TIL, loss of HLA class I, and overexpression of PD-L1 by tumor cells (PD-L1 TC) or immune cells (PD-L1 IC) were observed in 34 (58.6%), 27 (46.6%), 41 (70.7%), 45 (77.6%), 29 (50.0%), and 33 (56.4%) of 58 cases, respectively. Interestingly, the CD3-TIL score positively correlated with PD-L1 TC and PD1-TIL scores. HLA class I expression level was inversely correlated with the expression levels of PD-L1 TC and PD-L1 IC. Multivariate analysis showed that age, histology, and node metastasis were independent prognostic factors for 5-year overall survival (OS) and loss of HLA class I coincided with a positive prognosis (p = 0.011). The concomitant lack of infiltrating CD8+ T cells with no loss of HLA class I predicted worse 5-year OS (p = 0.007). Moreover, cluster classifications among multiple immunoparameters showed that categories among CD3/PD-L1 TC/HLA class I (p = 0.043), CD8/PD1/HLA class I (p = 0.032), CD8/PD-L1 TC/HLA class I (p = 0.011), and PD1/PD-L1 TC/HLA class I (p = 0.032) predicted 5-year OS in EPP cases for MPM. These immunoparameters could guide surgical indications for patients with MPM.

Right upper lobectomy for lung cancer with a displaced right bronchus: Two case reports.

Case 1 describe a 73-year-old man with an abnormal opacity in the upper lobe of the right lung on chest computed tomography (CT), which was done during the postoperative follow-up for bile duct cancer. The chest CT scan showed a ground glass nodule (GGN) measuring 1.0 cm and another one measuring 0.6 cm of the right lung. Case 2 involved a 79-year-old woman with an abnormal opacity in the upper lobe of the right lung on a chest CT that was obtained after she fell down the stairs. The CT scan showed a solid mass measuring 3.0 cm in the right upper lung. Both the patients underwent bronchoscopy before surgery and showed bronchial branching abnormalities. The surgical procedures could be performed accurately since sufficient information had been acquired pre-operatively and they diagnosed lung cancer. Both the patients were able to undergo radical surgery for lung cancer and are currently doing well with no postoperative complications or recurrence of lung cancer.

Malignant pleural mesothelioma with heterologous elements.

AIMS: Malignant pleural mesothelioma with heterologous elements (such as osseous, cartilaginous or rhabdomyoblastic differentiation) is very rare. We tried to differentiate such mesothelioma cases from extraskeletal pleural osteosarcoma, which is very challenging. METHODS: We compared 10 malignant pleural mesotheliomas (three biphasic and seven sarcomatoid types) with two pleural osteosarcomas using clinicopathological and immunohistochemical methods, and also fluorescence in situ hybridisation (FISH) to examine for homozygous deletion of p16. RESULTS: The median age was 72 years for mesotheliomas, and 69 years for osteosarcoma. For mesothelioma, eight cases were male and two were female. Growth was diffuse in all mesothelioma cases except case 10, where it was localised, as it was for the two osteosarcomas. Among mesothelioma cases, 80% displayed osteosarcomatous and 60% chondromatous elements, while 10% exhibited rhabdomyoblastic ones. Immunohistochemical labelling for calretinin and AE1/AE3 was present in 8/10 and 7/10 mesotheliomas, respectively, but in only one osteosarcoma. Loss of methylthioadenosine phosphorylase was seen in 5/7 mesotheliomas. FISH analysis revealed homozygous deletion of p16 in 5/8 mesothelioma and 2/2 osteosarcoma. Median survival was 6.5 months after biopsy or surgical operation in mesothelioma, and 12 months after operation in osteosarcoma. CONCLUSIONS: Although median survival was longer for osteosarcoma than for malignant mesothelioma, we could not differentiate mesothelioma from pleural osteosarcoma on the combined basis of clinicopathological and immunohistochemical data, and FISH analysis. However, diffuse growth was more frequent in mesothelioma than in osteosarcoma.

Tumor mutation burden as a biomarker for lung cancer patients treated with pemetrexed and cisplatin (the JIPANG-TR).

The JIPANG study is a randomized phase III study of pemetrexed/cisplatin (Pem/Cis) versus vinorelbine/cisplatin (Vnr/Cis) for completely resected stage II-IIIA non-squamous non-small cell lung cancer (Ns-NSCLC). This study did not meet the primary endpoint (recurrence-free survival, RFS) but Pem/Cis had a similar efficacy to Vnr/Cis with a better tolerability. Tumor mutation burden (TMB) is thought to have a predictive value of immune checkpoint inhibitors. However, the relevance of TMB to cytotoxic chemotherapy remains unknown. This exploratory study investigates the relationship between tumor mutation profiles and clinical outcome of Pem/Cis. Formalin-fixed, paraffin-embedded tumor tissues (n = 389) were obtained from the patients. Mutation status of tissue DNA was analyzed by targeted deep sequencing. Epidermal growth factor receptor (EGFR) mutations were detected frequently in Ns-NSCLC (139/374). Patients without any EGFR mutations experienced longer RFS in the Pem/Cis arm versus Vnr/Cis arms. Pem/Cis in patients with high TMB (≥12-16 mut/Mb) tended to have improved survival. In patients with wild-type EGFR, TMB ≥ 12 mut/Mb was significantly associated with improved RFS with Pem/Cis versus Vnr/Cis (not reached vs 52.5 months; hazard ratio (HR) 0.477). It could be proposed that TMB was predictive of RFS benefit with Pem/Cis versus Vnr/Cis in Ns-NSCLC. Further investigation is required to determine whether TMB combined with EGFR mutation status could be used as a predictive biomarker.

Penetrating pulmonary injury due to a thrown rusty nail while using a lawn mower: a case report.

Accidents while using lawn mowers are often reported, but chest injuries are rare. We report a case of a penetrating pulmonary injury due to a rusty nail thrown by a lawn mower. A 63-year-old man injured his left precordium by a thrown object while using a lawn mower; he thereafter visited a nearby hospital. A computed tomography image showed a left-sided pneumothorax and a penetrating pulmonary injury of the left upper lobe due to a foreign body. Pneumothorax was treated with thoracic drainage and resolved. He was transferred to our hospital on the second day after the injury, and video-assisted thoracoscopic surgery was performed to remove the foreign body. Surgical findings showed a penetrating wound in the left upper lobe and leakage of pus from its margin. The foreign body was a rusty nail. The penetrating wound was treated by partial pulmonary resection to control the infection. Histopathological findings revealed the formation of a lung abscess. Penetrating pulmonary injuries do not require surgical treatment for most patients. However, residual foreign bodies can cause lung abscesses. The removal of foreign bodies depends on the type of injury as well as the type and location of the foreign body. Theoretically, the foreign body should be removed and the penetrating pulmonary injury should be treated, if possible, to control infection.

Contralateral pulmonary resection using selective bronchial blockade in postpneumonectomy patients.

BACKGROUND: Pulmonary resection is occasionally performed in postpneumonectomy patients with contralateral lung lesions, such as metachronous or metastatic lung cancer. Careful intraoperative respiratory management is essential in such patients. This study evaluated the respiratory management of postpneumonectomy patients who underwent contralateral pulmonary resection with selective bronchial blockade of the lobe or segment to be resected. METHODS: We retrospectively analyzed the surgical findings and safety of surgery in six patients who underwent contralateral pulmonary resection with selective bronchial blockade after pneumonectomy for non-small cell lung cancer (NSCLC). RESULTS: The percutaneous oxygen saturation did not decrease in any of the patients during bronchial blockade under high oxygen concentration. The median blockade time was 57.5 minutes. The operative field was tolerable secured under conditions of partial lung collapse, and partial pulmonary resection was performed as planned. Postoperatively, one patient developed acute respiratory distress syndrome due to acute exacerbation of interstitial pneumonia; however, no patients died within one month postoperatively. Two patients underwent pulmonary resection in order to obtain adequate tissue specimens to evaluate the biomarkers of multiple lung metastases. On histopathology, one patient tested positive for anaplastic lymphoma kinase (ALK) and was subsequently administered an ALK inhibitor, which prolonged survival. CONCLUSIONS: In all patients, intraoperative respiratory condition under partial lung collapse remained stable, and all partial pulmonary resections were safely performed. However, surgical indications should be carefully reviewed preoperatively in patients with interstitial pneumonia. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Contralateral partial pulmonary resection was performed using selective bronchial blockade in postpneumonectomy patients. Percutaneous oxygen saturation did not decrease during the bronchial blockade under high oxygen concentration, and the operative field was tolerable secured under conditions of partial lung collapse. WHAT THIS STUDY ADDS: Oxygen concentration can be set to the minimum level, sufficient to maintain oxygenation, during contralateral partial pulmonary resection with selective bronchial blockade.

Multilocular thymic cyst in a patient with preclinical rheumatoid arthritis: A case report.

INTRODUCTION: Multilocular thymic cyst (MTC) is a rare condition of an acquired multilocular cystic lesion caused by inflammation and often associated with autoimmune diseases or malignant tumors. We present a patient with MTC and asymptomatic rheumatoid arthritis (RA), which is termed preclinical RA. PRESENTATION OF CASE: A 60-year-old man underwent a computed tomography scan, which revealed an 8.5 cm multilocular cystic lesion in the anterior mediastinum. The tumor had a lower intensity on T1-weighted imaging and a higher intensity on T2-weighted imaging. The imaging did not only suggest an MTC, but also the possibility of a thymoma with cystic degeneration, or lymphoma. We performed an extended thymectomy via median sternotomy. The lesion was diagnosed as MTC based on histopathological findings. Laboratory tests were performed for the purpose of screening for autoimmune diseases. He was diagnosed with preclinical RA, since the anti-cyclic citrullinated peptide antibody (ACPA) was positive. DISCUSSION: Specificity of ACPA is recorded in over 90% of patients with RA; ACPA is positive in about 40% of patients with preclinical RA. As patients with preclinical RA are more likely to develop RA, careful follow-up is required. Early diagnosis and treatment of RA can prevent destruction of joints, thereby preventing irreversible disability. CONCLUSION: In patients with MTC, evaluating the cause of the inflammation, such as autoimmune diseases, is essential. Further studies are required to investigate the relationship between MTC and preclinical RA.

Right upper lobectomy in lung cancer with double aortic arch: A case report.

Double aortic arch (DAA) is a rare congenital anomaly of the heart and aorta in which a vascular ring that surrounds the trachea and esophagus is formed. In most patients, respiratory distress and dysphagia develop in childhood, and asymptomatic adult patients are rarely known. Herein, we describe a patient with lung cancer and DAA. A 66-year-old man who had DAA underwent video-assisted thoracoscopic right upper lobectomy and mediastinal lymph node dissection for primary lung cancer. Lymph node dissection of the right upper mediastinum revealed that the right recurrent laryngeal nerve branched from the right vagus nerve just beneath the right aortic arch. Additionally, the right aortic arch narrowed the space surrounding the trachea, superior vena cava, and arch of the azygos vein, impeding the stapling of the truncus anterior artery and right upper lobe pulmonary vein with the video-assisted thoracoscopic approach. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: In double aortic arch, the recurrent laryngeal nerve branches from the vagus nerve just beneath the ipsilateral aortic arch. The right aortic arch narrows the space surrounding the trachea, superior vena cava, and arch of the azygos vein. WHAT THIS STUDY ADDS: The anatomy of a double aortic arch impedes mediastinal lymph node dissection on the ventral side of the trachea. Handling autosuture devices for stapling pulmonary arteries and veins is also difficult.

Rapid development and rupture of a pulmonary cyst in the early postoperative period after pulmonary resection: A case report.

Air leakage is a common complication after pulmonary resection, which is usually caused by direct lung damage during surgery. Herein, we describe a case in which a pulmonary cyst developed rapidly in the right lower lobe and ruptured 10 days after right upper lobectomy. A 49-year-old man, who was a heavy smoker, underwent thoracoscopic right upper lobectomy for primary lung cancer. No air leakage was observed postoperatively, and the chest drain tube was removed on postoperative day 1. Although his postoperative course was uneventful for more than a week, extensive subcutaneous emphysema developed unexpectedly on postoperative day 10. Computed tomography (CT) scan revealed a large pulmonary cyst in the right lower lobe that was not present before the right upper lobectomy. Surgery was performed on postoperative day 13, and it revealed a large thick-walled pulmonary cyst in the right lower lobe. The cyst was filled with blood clots, and air leaks were observed inside it, suggesting that the dissection of the pulmonary parenchyma caused its development. The cyst wall was sutured together with the pulmonary parenchyma, and no air leakage was subsequently observed. KEY POINTS: Significant findings of the study In patients with fragile pulmonary tissue, the pulmonary parenchyma may become dissociated after pulmonary resection and induce rapid development of a pulmonary cyst. Risk factors for pulmonary cyst development include upper lobectomy and emphysema. Pulmonary cysts are often formed in the lower lobe. What this study adds In patients with pulmonary emphysema post-upper lobectomy, the fragility of the pulmonary parenchyma and hyperinflation of the remaining lung may cause dissection of the pulmonary parenchyma, resulting in massive air leakage.

[Resection and Reconstruction of the Diaphragm and the Pericardium in Extrapleural Pneumonectomy].

The diaphragm dissection should be started from anterior, because the portion is just under the thoracotomy incision. The diaphragmatic muscle was cut by an electric knife along the line of 1 to 2 cm from the chest wall from anterior and lateral to posterior. The diaphragm including the tendon center is dissected from the peritoneum. The peritoneum should be preserved. If the peritoneum is opened, it should be repaired by sutures. The pericardium is opened at the apex. The pericardium incision is extended from the apex to cranial side. And then, it is cut from the apex to posterior with the diaphragm. And next, the incision of the cranial side edge is extended to posterior. The lower pulmonary vein, upper pulmonary vein, and pulmonary artery are exposed. They are encircled and divided in the pericardium by autosutures. A Goretex sheet with 1 mm thickness is used to reconstruct the diaphragm. Nine sutures were placed in advance for the Goretex, and pulled out from the chest cavity through upper and lower sides of the 10th or 9th rib. The sutures were tied outside the rib cage. For mediastinal side, the Goretex was sutured to the residual diaphragm. A Goretex sheet with 0.1 mm thickness is used to reconstruct the pericardium by interrupted sutures. Because the contralateral lung is overinflated, the reconstruction should not be tight. Slits for the Goretex are made to prevent regional tamponade.

Droplet digital PCR as a novel system for the detection of microRNA­34b/c methylation in circulating DNA in malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is a rare malignancy arising from the pleura that is difficult to diagnose, contributing to its dismal prognosis. Previously, we reported that the degree of microRNA (miR)­34b/c methylation in circulating DNA is associated with the development of MPM. Herein, we present a newly developed droplet digital PCR (ddPCR)­based assay for the detection of miR­34b/c methylation in circulating DNA in patients with MPM. We originally prepared two probes within a short amplicon of 60 bp, designing one from the positive strand and the other from the complementary strand. The two probes functioned cooperatively, and our established assay detected DNA methylation accurately in the preliminary validation. We subsequently verified this assay using clinical samples. Serum samples from 35 cases of MPM, 29 cases of pleural plaque and 10 healthy volunteers were collected from 3 different institutions and used in this study. We divided the samples into 2 groups (group A, n=33; group B, n=41). A receiver­operating characteristic curve analysis using the samples in group A determined the optimal cut­off value for the diagnosis of MPM, with a sensitivity of 76.9% and a specificity of 90%. On the other hand, the use of the same criterion yielded a sensitivity of 59.1% and a specificity of 100% in group B, and corresponding values of 65.7 and 94.9% for the entire cohort, indicating a moderate sensitivity and a high specificity. In addition, when the analysis was focused on stage II or more advanced MPM, the sensitivity improved to 81.8%, suggesting the possibility that the methylated allele frequency in MPM may be associated with the stage of disease progression. On the whole, the findings of this study indicate that miR­34b/c methylation in circulating DNA is a promising biomarker for the prediction of disease progression in patients with MPM.

Influence of intersegmental plane size and segment division methods on preserved lung volume and function after pulmonary segmentectomy.

OBJECTIVES: We previously reported that the use of a stapler to divide intersegmental planes did not decrease preserved pulmonary volume or function relative to electrocautery. However, preservation of pulmonary volume or function can be compromised when a stapler is used with larger intersegmental planes. Here, we assessed the correlations between preserved lung volume and pulmonary function after segmentectomy and the size of the intersegmental planes, based on the division method. METHODS: Intersegmental plane sizes in 56 patients were semi-automatically calculated using image analysis software on computed tomography images. The ratios of the remnant segment and ipsilateral lung volumes to their preoperative values (R-seg and R-ips) and the ratio of the postoperative pulmonary function relative to the predicted value were calculated based on three-dimensional volumetry. Correlations between preserved lung volume and pulmonary function and the intersegmental plane sizes were analyzed according to the division method. RESULTS: Intersegmental planes were divided by either electrocautery or with a stapler (EC/Mixed) in 21 patients and by stapler alone (ST) in 35 patients. There was no difference in the average size of the intersegmental planes between the two groups. The intersegmental plane size negatively correlated with R-seg in the ST group. CONCLUSIONS: Using the stapler method, as the size of the intersegmental planes increased, the preserved remnant segmental volume decreased; however, relation between the plane size and preserved pulmonary function was unclear. These findings indicate that stapler use is acceptable even for large intersegmental planes.

[Assessment of Fat-free Diet for Postoperative Chylothorax].

BACKGROUND: Chylothorax after lung cancer surgery is relatively rare but must be considered as a complication of thoracic surgery. METHOD: Between January 2012 and June 2017, 818 patients underwent lung cancer surgery at our hospital. Among them, 14 (1.7%) patients with chylothorax were retrospectively reviewed. Three patients were treated with oral intake cessation except water and total parental nutrition( TPN)[TPN group], 11 patients were treated with a fat-free diet( fat-free diet group). RESULTS: The drainage period was similar in both group [group TPN;13 (12~14) days and group fat-free diet;15.7 (6~42) days]. In the TPN group, 3 patients underwent pleurodesis and no patient needed surgical intervention. In the fat-free diet group, 5 patients improved only with diet management. Pleurodesis was necessary in 5 of which 3 underwent surgical intervention. CONCLUSIONS: A fat-free diet is useful in treating chylothorax after lung cancer surgery.

Preoperative risk assessment with computed tomography in patients undergoing lung cancer surgery.

BACKGROUND: Although whole lung computed tomography (CT) is included in the routine workup before lung cancer surgery, it is not utilized to assess the preoperative pulmonary function. METHODS: Two hundred ninety patients (development cohort) who underwent lung lobectomy for cancer in our institute and another 100 patients (validation cohort) who subsequently underwent the same operation in a referral hospital were included. The total lung volume (TLV) and emphysematous lung volume (ELV) were obtained by quantitative CT. RESULTS: The TLV was higher in patients with a smoking history than in those without. The ELV to the TLV was higher in elderly patients than in younger patients. The regression equation for forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were developed using CT-derived variables, together with sex, age, height, and smoking habit, by a multiple regression analysis in the development cohort. The regression equation-based FVC and FEV1 were significantly correlated with the actual FVC and FEV1 in the development cohort, as well as in the validation cohort. The predicted postoperative FEV1 (ppo%FEV1) calculated based on the regression equation was also correlated with the postoperative FEV1 value obtained by the conventional method (R=0.53), and the regression equation-based ppo%FEV1 was a significant predictor of postoperative cardiopulmonary complications (P=0.02). CONCLUSIONS: Whole lung CT can be used to assess the preoperative pulmonary function in patients undergoing lobectomy for cancer. This method may be helpful in preoperative risk assessment, particularly in patients who have difficulty in implementation of spirometry.