Tracheal bifurcation repair for blunt thoracic trauma in a patient with COVID-19.

BACKGROUND: Tracheobronchial injury (TBI) is a rare but potentially life-threatening trauma that requires prompt diagnosis and treatment. We present a case in which a patient with COVID-19 infection was successfully treated for a TBI through surgical repair and intensive care with extracorporeal membrane oxygenation (ECMO) support. CASE PRESENTATION: This is the case of a 31-year-old man transported to a peripheral hospital following a car crash. Tracheal intubation was performed for severe hypoxia and subcutaneous emphysema. Chest computed tomography showed bilateral lung contusion, hemopneumothorax, and penetration of the endotracheal tube beyond the tracheal bifurcation. A TBI was suspected; moreover, his COVID-19 polymerase chain reaction screening test was positive. Requiring emergency surgery, the patient was transferred to a private negative pressure room in our intensive care unit. Due to persistent hypoxia and in preparation for repair, the patient was started on veno-venous ECMO. With ECMO support, tracheobronchial injury repair was performed without intraoperative ventilation. In accordance with the surgery manual for COVID-19 patients in our hospital, all medical staff who treated this patient used personal protective equipment. Partial transection of the tracheal bifurcation membranous wall was detected and repaired using 4-0 monofilament absorbable sutures. The patient was discharged on the 29th postoperative day without postoperative complications. CONCLUSIONS: ECMO support for traumatic TBI in this patient with COVID-19 reduced mortality risk while preventing aerosol exposure to the virus.

Outcomes and pulmonary function after sleeve lobectomy compared with pneumonectomy in patients with non-small cell lung cancer.

BACKGROUND: Sleeve lobectomy is recommended to avoid pneumonectomy and preserve pulmonary function in patients with central lung cancer. However, the relationship between postoperative pulmonary functional loss and resected lung parenchyma volume has not been fully characterized. The aim of this study was to evaluate the relationship between pulmonary function and lung volume in patients undergoing sleeve lobectomy or pneumonectomy. METHODS: A total of 61 lung cancer patients who had undergone pneumonectomy or sleeve lobectomy were analyzed retrospectively. Among them, 20 patients performed pulmonary function tests, including vital capacity (VC) and forced expiratory volume in 1 s (FEV1) tests, preoperatively and then about 6 months after surgery. VC and FEV1 ratios were calculated (measured postoperative respiratory function/predicted postoperative respiratory function) as the standardized pulmonary functional loss ratio. RESULTS: Thirty-day operation-related mortality was significantly lower after sleeve lobectomy (3.2%) than pneumonectomy (9.6%). The 5-year relapse-free survival rate was 46.67% versus 29.03%, and the 5-year overall survival rate was 63.33% versus 38.71% in patients receiving sleeve lobectomy versus pneumonectomy. The VC ratio in the pneumonectomy group was better than in the sleeve lobectomy group (1.003 ± 0.117 vs. 0.779 ± 0.12; p = 0.0008), as was the FEV1 ratio (1.132 ± 0.226 vs. 0.851 ± 0.063; p = 0.0038). CONCLUSIONS: Both short-term and long-term outcomes were better with sleeve lobectomy than pneumonectomy. However, actual postoperative pulmonary function after pneumonectomy may be better than clinicians expect, and pneumonectomy should still be considered a treatment option for patients with sufficient pulmonary reserve and in whom sleeve lobectomy is less likely to be curative.

[A Case of Malignant Lymphoma of the Ileum and Uterine Cervix with Perforating Peritonitis of Ileum Tumor Detected during Chemotherapy].

A 77-year-old woman was admitted to our hospital because of right lower abdominal pain. CT revealed tumors in the ileum and uterine cervix. After a gynecological biopsy of the uterine tumor, we diagnosed Stage Ⅳ diffuse large B-cell lymphoma. We treated her with R-THPCOP chemotherapy. On day 8 after the first chemotherapy, she developed perforated peritonitis, and an emergency partial ileum resection was performed. Histopathologically, viable cells were not found in the resected intestine. Chemotherapy was resumed on postoperative day 21, and she achieved a complete response 8 months after the surgery. Gastrointestinal malignant lymphoma is sometimes reported in cases requiring emergency surgery. Therefore, information sharing between hematologist and surgeon is recommended.

Accuracy of helical computed tomography for the identification of lymph node metastasis in resectable non-small cell lung cancer.

PURPOSE: The criteria for the diagnosis of lymph node metastasis (LNM) in non-small cell lung cancer were investigated using helical computed tomography (hCT). The conventional criterion (1-cm short axis threshold) is generally accepted; however, this criterion is based on conventional CT. New criteria for LNM were investigated because the resolution of hCT is better than that of conventional CT. METHODS: Ninety-seven NSCLC patients examined with hCT were enrolled. Both the long axis (LA) and short axis (SA) of the nodes were measured using hCT. RESULTS: Based on the receiver operating characteristic curves, the thresholds that gave optimal sensitivity and specificity for LNM were 13 mm for LA and 9 mm for SA. The LNM diagnosis was re-evaluated using the combination of cutoff values. When the LA was > or =13 mm and the SA was > or =9 mm, the sensitivity, specificity, and accuracy were 56.3%, 92.1%, and 88.1%, respectively. When the LA was > or =13 mm or SA was > or =9 mm, sensitivity, specificity, and accuracy were 75.0%, 74.7%, and 74.7%, respectively. These values were not so different from the conventional criterion recalculated from these data. CONCLUSION: The new criteria are considered to be useful for making a LNM diagnosis. The conventional criteria for the LNM diagnosis might therefore be applicable even for hCT.

[A case of survival--excellent response to chemotherapy in long-term postoperative recurrence of non-small cell lung cancer].

A 63-year-old female underwent lobectomy with ND2a lymph node dissection for left lung cancer in April 1999. Histopathological examination revealed moderately-differentiated adenocarcinoma (pT2N2M0, pStage III A). She received one course of a combination of etoposide (ETP) and cisplatin(CDDP)as adjuvant therapy, followed by oral intake of UFT. At 9 months post-operatively, she received radiation therapy for lymph node recurrence, at which time new multiple lung metastases were found. After receiving 3 courses of a combination of vinorelbine (VNR) and CDDP, a complete response (CR) of all metastatic lesions was achieved. Three years after the original surgery, metastatic lesions recurred, and a total of 9 courses of a combination of VNR and carboplatin (CBDCA) and partial resection of the right lung for pulmonary metastasis were performed in succession. Following this therapy, treatment with gefitinib was initiated for about 6 months, and computed tomography (CT) showed progressive disease. For 8 years following the original operation, the patient received oral chemotherapy using S-1 and has maintained CR on CT. We conclude that oral administration of S-1 is useful as palliative chemotherapy without serious adverse events or worsening of quality of life. Patients like this case are thus able to continue chemotherapy for a long time.

Mediastinal neurofibroma originating from the left intrathoracic phrenic nerve: report of a case.

We report a case of mediastinal neurofibroma originating from the left phrenic nerve in a 42-year-old woman who was referred to us after a routine chest X-ray showed a smooth, round abnormal shadow in the left middle lung field adjacent to the heart. We resected a 25 x 20 x 20-mm tumor by video-assisted thoracic surgery. Histopathological examination confirmed that the lesion was a mediastinal neurofibroma originating from the left phrenic nerve without von Recklinghausen's disease. Neurogenic mediastinal tumors originating from the phrenic nerve are very rare, and to the best of our knowledge, no other case of a mediastinal neurofibroma originating from the phrenic nerve in a patient without von Recklinghausen's disease has ever been reported.

Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery.

OBJECTIVE: Widespread clinical use of helical computed tomography has improved the detection rate for small peripheral pulmonary nodules. As a result, use of thoracoscopic surgery to confirm the diagnosis of small peripheral pulmonary nodules has become more important than ever before. However, if small peripheral pulmonary nodules are too small or located too deeply to detect thoracoscopically, it is necessary to mark the small peripheral pulmonary nodules preoperatively. The purpose of this study was to determine indications for preoperative hookwire marking in thoracoscopic resection of small peripheral pulmonary nodules. METHODS: A total of 120 patients underwent thoracoscopic pulmonary resection in our institute from 1999 to 2001. Small peripheral pulmonary nodules were marked preoperatively in 61 of these patients by means of percutaneous placement of a hookwire under computed tomographic guidance. The hookwire-marked small peripheral pulmonary nodules either were smaller than 10 mm or were located more than 10 mm below the pleural surface. RESULTS: Although 9 of the hookwire-marked small peripheral pulmonary nodules were easily identified during thoracoscopy, the other 52 small peripheral pulmonary nodules could not have been identified during thoracoscopy without the hookwire marking. Of the 59 small peripheral pulmonary nodules that were not hookwire marked, 7 required conversion to thoracotomy to locate the nodules. Small peripheral pulmonary nodules from both groups were examined and assigned to either an undetectable or detectable group. Discriminant function analysis indicated that a linear function (ie, depth = 0.836 x size - 2.811) could be used to differentiate between undetectable and detectable small peripheral pulmonary nodules, and preoperative hookwire marking for small peripheral pulmonary nodules should be considered for nodules in the region above those. CONCLUSION: The results suggest that this formula might serve as an indication for preoperative marking of small peripheral pulmonary nodules in thoracoscopic resection.

Nafamostat mesilate attenuates radical formation in the rat lung infused with endotoxin.

We previously reported direct evidence of respiratory bursting by neutrophils in the pulmonary circulation of endotoxin-infused rats. To evaluate the effect of the protease inhibitor nafamostat mesilate (NM) on leukocyte-mediated radical formation in the pulmonary circulation of rats infused with endotoxin, we observed and measured the number of sticking leukocytes and quantified radical production in the pulmonary circulation of endotoxin-infused rats by means of a fluorescent imaging technique. Plasma C3a (desArg) was also measured using an enzyme-linked immunosorbent assay. Three groups (n = 5) of rats were infused with 4.5 mg/kg/h endotoxin (Et group), 50 microg/kg/h NM + endotoxin (NM group), or physiological saline (Ct group) for 2 h. The number of the leukocytes adhering within pulmonary capillaries, oxygen radical production in the rat pulmonary circulation, and plasma C3a (desArg) were all lower in the NM group than in the Et group. The leukocytes producing oxygen radicals were confirmed to be neutrophils by electron microscopic analysis of cerium deposition. We conclude that NM attenuates plasma C3a formation, neutrophil adherence to pulmonary capillaries, and their production of oxygen radical in rats infused with endotoxin.