Atypical Segmentectomy Research Articles

Clinicopathological features and surgical outcomes of lobectomy combined with segmentectomy: a cohort study.

Segmentectomy is a standard procedure, and there is considerable data on routine segmentectomies. However, there are only few reports on lobectomy performed in combination with segmentectomy (lobectomy + segmentectomy). Thus, we aimed to clarify the clinicopathological features and surgical outcomes of lobectomy + segmentectomy. We reviewed patients who underwent lobectomy + segmentectomy between January 2010 and July 2021 at Gunma University Hospital, Japan. We comparatively analyzed clinicopathological data of patients who underwent lobectomy + segmentectomy and those who underwent lobectomy in combination with wedge resection (lobectomy + wedge resection). We collected data from 22 patients who underwent lobectomy + segmentectomy and 72 who underwent lobectomy + wedge resection. Lobectomy + segmentectomy was mainly performed to treat lung cancer, and the median number of resected segments was 4.5 and the median number of lesions was 2. Lobectomy + segmentectomy was associated with a higher rate of thoracotomy and a longer operation time. Incidence of overall complications, including pulmonary fistula and pneumonia was higher in the lobectomy + segmentectomy group. However, there were no significant differences in the length of drainage, major complications, and mortality. For lobectomy + segmentectomy, the only left-sided procedure was a left lower lobectomy + lingulectomy, whereas procedures were diverse on the right side, mostly combining a right upper or middle lobectomy with atypical segmentectomies. Lobectomy + segmentectomy was performed for (I) multiple lung lesions, (II) lesions invading an adjacent lobe, or (III) lesions with a metastatic lymph node invading the bronchial bifurcation. Although lobectomy + segmentectomy is a lung-preserving procedure that can benefit patients with multiple or advanced diseases involving two lobes, this procedure should still be performed following a careful patient selection process.

Smoking Habit and Respiratory Function Predict Patients’ Outcome after Surgery for Lung Cancer, Irrespective of Histotype and Disease Stage

Growing evidence suggests that sublobar resections offer more favorable outcomes than lobectomy in early-stage lung cancer surgery. However, a percentage of cases that cannot be ignored develops disease recurrence irrespective of the surgery performed with curative intent. The goal of this work is thus to compare different surgical approaches, namely, lobectomy and segmentectomy (typical and atypical) to derive prognostic and predictive markers. Here we analyzed a cohort of 153 NSCLC patients in clinical stage TNM I who underwent pulmonary resection surgery with a mediastinal hilar lymphadenectomy from January 2017 to December 2021, with an average follow-up of 25.5 months. Partition analysis was also applied to the dataset to detect outcome predictors. The results of this work showed similar OS between lobectomy and typical and atypical segmentectomy for patients with stage I NSCLC. In contrast, lobectomy was associated with a significant improvement in DFS compared with typical segmentectomy in stage IA, while in stage IB and overall, the two treatments were similar. Atypical segmentectomy showed the worst performance, especially in 3-year DFS. Quite unexpectedly, outcome predictor ranking analysis suggests a prominent role of smoking habits and respiratory function, irrespective of the tumor histotype and the patient's gender. Although the limited follow-up interval cannot allow conclusive remarks about prognosis, the results of this study suggest that both lung volumes and the degree of emphysema-related parenchymal damage are the strongest predictors of poor survival in lung cancer patients. Overall, these data point out that greater attention should be addressed to the therapeutic intervention for co-existing respiratory diseases to obtain optimal control of early lung cancer.

Minimally invasive assisted surgeries in surgical treatment of patients with chemoresistent tuberculosis

Objective — to analyze in our own experience the possibility of using minimally invasive video-assisted resection surgery in the surgical treatment of patients with chemoresistant tuberculosis.
 Materials and methods. An analysis of the results was conducted application of 79 VATS resections in patients with HRTB for the period from 2008 to 2022. When selecting candidates for VATS resection, preference was given to patients with limited peripheral processes.
 Results and discussion. Among the operated patients in almost half of the cases a typical VATS-lobectomy was performed — 40 (50.6 %). The most common typical upper lobectomy on the right was 14 (16.8 %) observations. In second place in terms of frequency are segmental resections: typical segmentec­tomy — 16 (19.2 %); atypical segmentectomy — 11 (13.2 %) observations. Other types of VATS resections were performed less frequently: pulmonectomy — 5 (6 %), lower whitebectomy — 3 (3.6 %), combined resection of the lower lobe and S6 — 4 (4.8 %) observations.The most frequently studied patients were operated on for tuberculosis 36 (43.2 %), on the second stage of the operation were performed for pulmonary FCT — 33 (39.6 %) observations. There were 4 (4.8 %) patients operated on for cerotic tuberculosis. Pulmonary FCT — 33 (39.6 %). Operations for pneumothorax, hemoptysis and HRT complicated by aspergilloma were performed 2 (2.4 %) in each of the nosologies. The results show that the indications for VATS operations were limited forms of HRTB.
 Conclusions. VATS-resections of the lung lobe are minimally invasive and promising treatments that provide anatomical preparation of the elements of the root of the lung. They can be considered as an alternative to open lobectomy. Extensive use of this method is hampered by severe pulmonary fibrosis and the connective tissue process, due to the long inflammatory process and long-term medical treatment, and the cost of endoscopic instruments.

Inflammatory pseudotumor and myofibroblastic inflammatory tumor. Diagnostic criteria and prognostic differences

IntroductionInflammatory pseudotumor (IPT) and inflammatory myofibroblastic tumor (IMT) are two very rare entities that were formerly included in the same category; however, today they are considered two different diseases due to the neoplastic origin of the IMT. Our objective is to share our experience in the management of these two types of tumors that we must take into account in the differential diagnosis of pulmonary masses or nodules. MethodsThirteen patients with a pathological diagnosis of IPT and IMT who underwent surgery between 2008 and 2019 were retrospectively studied. We recorded the pre and postoperative information of each one, as well as the survival analysis. ResultsOf the 13 patients, 8 were men and 5 women. The mean age of presentation was 53,5 years. An atypical segmentectomy was performed in 6 patients; a lobectomy was necessary in 6 and a pneumonectomy in 1 case. In all cases a complete resection was achieved. Diagnosis was possible thanks to histology, immunohistochemical (IHQ) and fluorescent in situ hybridization (FISH) techniques determining the expression of IgG4 and the rearrangement of ALK, respectively. After a median follow up of 49 months, we didn’t find any loco-regional or distant recurrence in the patients studied. ConclusionIPT and IMT are rare tumors with a very good prognostic. The diagnosis of both entities is based mainly on specific anatomopathological techniques. Surgery has, in most cases, both a diagnostic and therapeutic role.

"Non-Triangle Plane" Surgical Technique of Video-Assisted Thoracic Surgery Atypical Segmentectomy for Stage IA Non-Small-Cell Lung Cancer: Early Experience.

Objectives: To evaluate the safety and feasibility of a novel surgical technique (“non-triangle plane” technique) of two-port (mini-utility) video-assisted thoracic surgery (VATS) atypical segmentectomy (S3+S1+2c) with tunneling stapler for small-sized non-small-cell lung cancers (NSCLCs) located in left S3 close to the intersegmental plane between S3 and S1+2c.Materials and Methods: This retrospective descriptive study included 16 patients who, between April 2016 and December 2019, underwent a single two-port (mini-utility) VATS atypical segmentectomy (S3+S1+2c) with tunneling stapler technique for small-sized NSCLCs with a ground-glass opacity (GGO) rate of more than 50% by a constant surgical team in two hospitals. Perioperative data and survival data were collected and retrospectively analyzed. Postoperative follow-up was performed every 6 months.Results: Six patients were with adenocarcinoma in situ, and ten were with minimally invasive adenocarcinoma. The mean surgical margin was 14.06 ± 3.02 mm. The mean operation time was 53.88 ± 9.76 min. The mean duration of chest tube drainage was 4 ± 1.21 days, and the median length of postoperative hospital stay was 4 days. There was no perioperative morbidity and mortality. The median follow-up was 47.5 months (17–61 months). No recurrences occurred, and all patients were still alive at the last registered follow-up (May 31, 2021).Conclusion: Two-port (mini-utility) VATS atypical segmentectomy (S3+S1+2c) with tunneling stapler technique is a safe and feasible option for the treatment of small-sized NSCLCs located in left S3 close to the intersegmental plane between S3 and S1+2c.

Analysis of modern anesthetic approaches in endoscopic phthisiosurgery

Objective — to analyze modern anesthetic approaches and their use in endoscopic phthisiosurgery.
 Materials and methods. During 2008—2021, we performed 133 VATS lung resections in patients with tuberculosis. The following VATS operations were performed: atypical segmentectomy — 29 (21.6 %), typical segmentectomy — 49 (36.9 %), lobectomy — 49 (36.9 %) cases, bilobectomy — 2 (1.5 %), pulmonectomy — 4 (3.1 %) observations.The number of patients diagnosed with newly diagnosed tuberculosis was 62 (46.3 %), with multidrug­resistant tuberculosis 45 (34.4 %) and extensively drug-resistant tuberculosis 26 (19 3 %). One-pulmonary ventilation, which was carried out by endobronchial intubation of the main bronchus of the contralateral lung using a double-lumen tube (DLT) in 115 (86.4 %) patients, in 15 (11.3 %) cases, endobronchial intubation was performed with a single-lumen tube (SLT) and in 3 (3.1 %) tracheal intubation.
 Results and discussion. The use of a DLT for intubation made it possible to reduce the duration of surgery by 20—25 % compared with the use of a SLT or tracheal intubation. When using a DLT, a more stable, faster and better collapse of the lungs was achieved, which in turn gave a decrease in trauma to its parenchyma due to the fact that additional instrumental actions were not required on the part of surgeons to achieve it.Intraoperative blood loss with DLT was (75.4 ± 38.7) and (112.6 ± 51.8) ml with SLT in experiments with intubation of the main bronchus of the contralateral lung and (184.3 ± 89.8) ml in tracheal intubation, largely due to visualization and comfort working conditions of the surgical team.In the recovery of costs, we adhere to restrictive infusion approaches, which allows avoiding overloading the pulmonary circulation, and therefore reducing the number of pulmonary complications. The qualitative composition of the intraoperative infusion program included crystalloid and colloidal solutions. The quantitative ratio during the intubation of DLT was 3 : 0.5, with SLT 3 : 1. The need for transfusion of blood components was only during tracheal intubation.
 Conclusions. The most important task of modern anesthesiology in endoscopic phthisiosurgery is to improve patient safety during surgery. The defining technologies of anesthetic protection in this case should be the following categories: means and methods of general anesthesia, methods of respiratory provision and technical means of their application; full intraoperative monitoring of vital functions.

Superior Lingular S4 Segmentectomy

Although segmentectomy has become a routine procedure, atypical segmentectomies are less popular than their typical counterparts, probably because anatomic and surgical data are lacking. The left superior lingular S4 segment is considered relatively small, usually resected along with other segments. However S4 segment size varies among patients, and resection of this single segment can be a valuable lung-preserving procedure in carefully selected patients with tumors located at the border of the upper division and lingular segments. We present here the anatomic and surgical features required for a methodologic left S4 segmentectomy based on our experience and the literature.

Seudotumor inflamatorio y tumor miofibroblástico inflamatorio. Criterios diagnósticos y diferencias pronósticas

IntroductionInflammatory pseudotumor (IPT) and inflammatory myofibroblastic tumor (IMT) are two very rare entities that were formerly included in the same category; however, today they are considered two different diseases due to the neoplastic origin of the IMT. Our objective is to share our experience in the management of these two types of tumors that we must take into account in the differential diagnosis of pulmonary masses or nodules. MethodsThirteen patients with a pathological diagnosis of IPT and IMT who underwent surgery between 2008 and 2019 were retrospectively studied. We recorded the pre and postoperative information of each one, as well as the survival analysis. ResultsOf the 13 patients, 8 were men and 5 women. The mean age of presentation was 53,5 years. An atypical segmentectomy was performed in 6 patients; a lobectomy was necessary in 6 and a pneumonectomy in 1 case. In all cases a complete resection was achieved. Diagnosis was possible thanks to histology, immunohistochemical (IHQ) and fluorescent in situ hybridization (FISH) techniques determining the expression of IgG4 and the rearrangement of ALK, respectively. After a median follow up of 49 months, we didńt find any loco-regional or distant recurrence in the patients studied. ConclusionIPT and IMT are rare tumors with a very good prognostic. The diagnosis of both entities is based mainly on specific anatomopathological techniques. Surgery has, in most cases, both a diagnostic and therapeutic role.

Robotic Surgery and Anatomic Segmentectomy: An Analysis of Trends, Patient Selection, and Outcomes

BackgroundWhether robotic segmentectomies are advantageous is unclear. We describe our experience with the robot, comparing patient populations and outcomes with video-assisted thoracoscopic surgery (VATS) and open resection. MethodsPatients who underwent anatomic segmentectomy from 2004 to 2019 were reviewed. Resection methods were categorized as robotic, VATS, or open. Segmentectomies were categorized as simple or complex. Baseline characteristics and perioperative outcomes were analyzed from 2015 to 2019 due to implementation of the Enhanced Recovery After Surgery pathway for all thoracic surgery patients and to thus minimize confounders resulting from the Enhanced Recovery After Surgery protocol. ResultsSince 2004, an increase has occurred in segmentectomies, including robotic and complex segmentectomies. Of the 222 segmentectomies performed from 2015 to 2019, 77 (35%) were robotic, 40 VATS (18%), and 105 open (47%). More complex segmentectomies were performed in the robotic group compared with VATS and open (45% vs 15% vs 22%; P < .001). Operative time for robotic resections were longer compared with VATS and open (205 vs 147 vs 147 minutes; P < .001) but had lower blood loss (50 vs 75 vs 100 mL; P < .001) and shorter chest tube days (2 vs 2 vs 3 days; P = .004) and lengths of stay (3 vs 3 vs 4 days; P < .001). Perioperative mortality was low in all groups. No robotic segmentectomy was converted to open compared with 7.5% for VATS (P = .038). Prolonged air leak was lower for robotic compared with open (4% vs 13%; P = .038). ConclusionsRobotic segmentectomy has increased in our institution, with a concurrent rise in atypical segmentectomies. Despite performing more complex procedures, there were no conversions and low perioperative morbidity and mortality. Our results suggest that the robotic platform can facilitate performance of complex anatomic segmentectomies.

Segmentectomy Guided by 3-Dimensional Images Reconstructed From Nonenhanced Computed Tomographic Data

Three-dimensional (3D) imaging is an essential tool for performing an accurate segmentectomy. However, data acquired from contrast-enhanced computed tomography (CT) are considered necessary when reconstructing 3D pulmonary vascular images. Therefore, 3D images are currently unavailable for patients who cannot undergo contrast-enhanced CT scans due to patient-related issues such as anaphylaxis to the contrast agent, among others. We present here our experience with atypical segmentectomies guided by 3D images reconstructed from nonenhanced CT data.

Evaluation of the Residual Lung Function After Thoracoscopic Segmentectomy Compared With Lobectomy

Segmentectomy has shown a beneficial effect on preserving lung function after resection. However, the preservable lung volume and changes after thoracoscopic segmentectomy remain unknown. We compared the residual lung function after thoracoscopic segmentectomy and lobectomy, using a novel three-dimensional computed tomography-based volumetric method. Seventy-four patients who received thoracoscopic segmentectomy were matched to the 74 patients who received thoracoscopic lobectomy. Spirometry and computed tomography were performed before and 6 months after resection, and the ipsilateral residual preserved and nonoperated lobe volume and the contralateral lung volume were calculated using three-dimensional computed tomography. The percentage of actual/predicted regional forced expiratory volume in 1 second (the preservation rate) in each lobe (measured by volumetry and spirometry) was compared with the extent of resection and procedural difficulty (typical or atypical segmentectomy). The postoperative lung function was significantly more well preserved in segmentectomy than in lobectomy. After segmentectomy and lobectomy, the regional forced expiratory volume in 1 second of the ipsilateral unaffected lobe was increased in comparison with the preoperative value, whereas that of the residual lobe rescued by segmentectomy was decreased. The preservation rates of the residual and unaffected lobes were inversely and positively correlated, respectively, with the extent of the resected segment. The preservation rates of the residual lobe after typical or atypical segmentectomy were not significantly different. Although the decrease in the actual lung function of the residual lobe was greater than predicted and increased with increasing extent of resection, segmentectomy preserved the whole lung function better than lobectomy.

Segmentectomy in patients with primary pulmonary malignancies

To analyze immediate and long-term results of anatomical resections for lung cancer with subsequent comparison of the results of segmentectomy and lobectomy in patients with peripheral NSCLC stage IA1-2. There were 52 sublobular anatomical resections of the lung for peripheral non-small cell carcinoma and carcinoid T1a-bN0M0, IA1-2 stage. 3D-CT reconstruction with separation of bronchial and vascular structures was used to schedule complex segmentectomy. We retrospectively analyzed 200 patients with cT1a-bN0M0 peripheral non-small cell lung cancer (NSCLC) and tumor dimension ≤2 cm who underwent lobectomy (n=148) and segmentectomy (n=52). Mortality, morbidity and overall 5-year survival were compared in two propensity score matched groups (46 pairs, segmentectomy vs. lobectomy). There was no mortality in both groups. Morbidity was similar after segmentectomy and lobectomy (8.69 and 6.52%; p=0.32). 3D-CT with separation of bronchial and vascular structures enabled surgeons to perform atypical segmentectomies and VATS procedures more often (from 13.5 to 31.3%; p>0.05 and from 11.5 to 50.0%; p<0.05). Five-year survival was 82 and 86% (p=0.652) after segmentectomy and lobectomy, respectively. Postoperative results and long-term outcome after segmentectomy and lobectomy are comparable in patients with NSCLC cT1a-bN0M0, stage IA1-2. Segmentectomy is advisable surgery in patients with low pulmonary capacity and severe comorbidities.

P53 Cryptococom as a Differential Diagnosis of Pulmonary Metastase in a Patient with Challenging Adenocarcinoma: Case Report

Pulmonary cryptococcosis is a potentially serious fungal disease that may have several clinical presentations. Radiologically, it can be found as single or multiple nodules, thus being able to mimic primary neoplasms of lung or metastasis. It usually presents asymptomatically and is detected by incidental radiological findings. Retrospective case report based on medical record analysis, surgical pathology result and immunohistochemical evaluation. The present report describes the case of a female patient, 42 years old, who presented with rectum adenocarcinoma for 2 years, who had already undergone chemotherapy and radiotherapy, and was considered to have eradicated disease. During control examinations, the presence of pulmonary nodule in the basal segment of the right lower lobe, in the upper left apical segment and in the posterior apex of the left upper lobe, with characteristics of pulmonary metastases, was evidenced in Thoracic Computed Tomography (CT). She was then admitted to the Thoracic Surgery Service of the Oswaldo Cruz University Hospital (HUOC-Recife), and atypical segmentectomy was performed to remove right nodulation. The anatomopathological result of the surgical resection showed cryptococoma, being indicated, together with the Service's pulmonology, the accomplishment of systemic treatment for cryptococcosis, in addition to a new surgical approach for the removal of contralateral cryptococoma. Thus, the differential diagnosis of infectious diseases, even with any scenario conducive to neoplasia, is essential. The benefit of doubt in such cases may not only change prognosis but also add disease-free survival. In this new context, therefore, it is urgent to create a specific treatment standard, either with systemic therapy or alone.

S2 segmentectomy of the right upper lobe: an uncommon but very useful segmentectomy

Compared to lobectomy, performing a segmentectomy needs more experience and anatomical knowledge, in particular atypical segmentectomies like S 2 resection. It is considered an uncommon but very useful procedure for the treatment of patient with early stage lung cancer in the right upper lobe. Here, we present two cases of patients with different anatomies of hilar structures in the S 2 segment of the right upper lobe. Case 1: an 82-year-old male patient came to our attention for a chest CT-scan finding of a 13 mm solid nodule in the S 2 segment of the right upper lobe. The patient was in follow up and no regression of the lesion was seen in the last CT scan. As we considered the lesion highly suspicious of early stage lung cancer, a surgical excision was proposed. So, a right S 2 segmentectomy by minimally invasive approach was carried out. Case 2: a 42-year-old female patient presented to our attention for a chest CT-scan finding of a 20 mm mixed-ground-glass opacity (GGO) in the S 2 segment of the right upper lobe. The patient was in follow up and no regression of the lesion was seen in the last CT scan. As we considered the lesion highly suspicious for a tumour, a surgical excision was proposed. A right S 2 segmentectomy by minimally invasive approach was performed. The post-operative course was uneventful in both patients. Final histopathological examination revealed an invasive mucinous adenocarcinoma of the lung, staged as pT1bN0M0 for the case 1 and an invasive papillary adenocarcinoma of the lung, staged as pT1bN0M0 for the case 2. S 2 segmentectomy is an uncommon, demanding, but very useful surgical procedure. The most difficult part lies in how to identify a recurrent A 2 and the right B 2 . A clear understanding of different anatomies is critically important to complete a successful procedure.

VATS segmentectomy: past, present, and future.

Video-assisted thoracoscopic surgery (VATS) has gradually been implemented in thoracic surgery, and the VATS approach has now been extended to technically challenging procedures, such as segmentectomy. The definition of VATS segmentectomy is changing over time, and the repertoire of segmentectomy is getting wider with increasing reports on atypical segmentectomy. VATS segmentectomy bears surgical, oncological, and technical advantages; however, there are still areas of controversy, particularly regarding oncological outcomes. The indication of VATS segmentectomy is diverse and is used for treating lung cancer, metastatic lung tumors, or a variety of nonmalignant diseases. It is particularly valuable for the lung-sparing resection of deeply located small nodules or repeated surgery for multiple lung lesions. VATS segmentectomy requires a thorough analysis of segmental anatomy and a tailored preoperative planning with the assessment of surgical margins. Technical challenges include intraoperative navigation, methods to identify and dissect the intersegmental plane, and the prevention of air leakage. This review will discuss the present state of VATS segmentectomy, with a focus on past studies, current indications and techniques, and future view.

P3.04-020 Segmentectomy in Patients with Pulmonary Malignancies Using 3D-CT Reconstruction and Bronchovascular Separation: Topic: Miscellaneous I

Progress in diagnostics and surgery in thoracic oncology is associated with increasing number of patients-candidates for sublobar anatomic pulmonary resection. Vascular variability of pulmonary segments anatomy requires special tools for individual preoperative planning. 84 patients who underwent segmentectomy due to low pulmonary function, severe comorbidity, previous history of lung resection and metastatic lesion were included at the retrospective trial from prospectively collected database. Inclusion criteria were clinical T1aN0M0 peripheral non-small cell lung cancer (NSCLC) measuring ≤2 cm (n=23) and resectable pulmonary metastases not suitable for wedge resection due to deep parenchymal location (n=61). Segmentectomies were divided into typical (where parenchymal division involves 2 planes) and atypical (more complex and technically demanding, when the segmental excision involves 3 planes). 19 patients underwent VATS segmentectomy. Three-dimensional computed tomography (3D-CT) with bronchovascular separation was used preoperatively in 32 patients from October 2014 to May 2016. Mortality, morbidity, proportion of typical versus atypical and VATS versus open segmentectomies in two groups: with or without 3D-CT bronchovascular reconstruction, were compared. There was no mortality in whole group. Morbidity rate was 14% not exceeding grade 3a according thoracic mortality and morbidity (TMM) score. The difference in morbidity rate was not statistically significant between two groups (15,3% and 12,5%; p=0,64) The most common complication was prolonged air leak > 7 days (8%). 3D-CT powered by separation of arterial, venous and bronchial structures enabled surgeons to perform atypical segmentectomies and use VATS approach more often (37% vs 4% and 42% vs 16%, respectively). 7 atypical segmentectomies were performed by VATS due to 3D-CT reconstruction with bronchovascular separation. 3D-CT reconstruction with bronchovascular separation provides precise preoperative planning of individual pulmonary segments anatomy and enables to increase the proportion of atypical and VATS sublobar anatomic pulmonary resections.

New Technique for Lung Segmentectomy Using Indocyanine Green Injection

One of the most difficult aspects of complete segmentectomy of the lung is the identification of the intersegmental plane. Instead of a conventional residual segment inflation method, we have developed a new technique for detecting intersegmental planes using indocyanine green medium. The technique is simple and consists of (1) ligation of the segmental vein to prevent loss of the indocyanine green and (2) injection of indocyanine green through the segmental bronchus. These two steps result in easy identification of intersegmental planes by a change of color not only of the surface but also of the parenchyma of the lung. This technique can be indicated for atypical segmentectomy.

Subcutaneous Botulinum Toxin for Chronic Post‐Thoracotomy Pain

Botulinum toxin is a neurotoxin that has been widely used in chronic pain for the treatment of multiple conditions with a component of localized muscle spasm. Recent studies suggest that botulinum toxin is effective in the treatment of neuropathic pain syndromes such as post-herpetic neuralgia. We report the case of a 67-year-old man who underwent atypical segmentectomy of a right lower lobe lung nodule. The patient was referred to our pain management department with a of 2-year history persistent pain along the thoracotomy scar having a predominantly neuropathic component, refractory to standard treatments. He was successfully treated with subcutaneous botulinum toxin type A. On the basics of our own experience and on the analysis of the reports published in the literature, fractioned subcutaneous injections of botulinum toxin may be useful for the treatment of various chronic localized pain conditions including chronic post-thoracotomy pain.

Spontaneous pneumothorax and tuberculosis: long-term follow-up

Though spontaneous pneumothorax (SP) is a well-known complication of pulmonary tuberculosis (TB), there are very few reports addressing this topic. For this reason, we retrospectively analysed the experience of SP in patients diagnosed with TB in our hospital between 1989 and 2010. Out of 872 patients treated for SP during this period, 47 (5.4%) had TB antecedents, 21 with active TB (0.95% of the 2,089 TB cases diagnosed during this period) and 26 with residual inactive TB. 46 cases were treated with pleural drainage (PD): 40 (85%) with only one PD, two with two, and four with three. The mean ± SD length of PD treatment was 12.9 ± 11.3 days. In 11 (23%) cases, a relapse of SP occurred, with no statistical relationship between the different studied variables. In 13 (28%) cases, it became necessary to carry out a resection (atypical segmentectomy in all cases) for persistent air leaks with PD. Survival statistics were unfavourable only in elderly patients and those infected with HIV. We conclude that the treatment of SP secondary to TB with PD is usually a sound response, with a good general prognosis and a low percentage of cases that require another PD and surgical treatment.

A case of intralobar pulmonary sequestration treated by video-assisted thoracic atypical segmentectomy

血痰を主訴とした20代男性の左肺下葉肺分画症に対して，胸腔鏡下手術で治療したので報告する．症例は造影CTにて胸部下行大動脈から左肺下葉へ直接分岐する異常血管を認め，肺分画症の診断で当院に紹介となった．入院後胸部3D-CTにて肺葉内肺分画症と診断し，胸腔鏡補助下に左下葉非定型的区域切除を施行した．近年，肺分画症に対する胸腔鏡手術の報告は散見されるが，肺葉内肺分画症に対して胸腔鏡補助下に区域切除を施行した症例の報告は少ない．肺分画症は胸部3D-CT等の画像診断により，術前に流出入血管の走行を十分に確認できることが多く，良性疾患であることから術後呼吸機能の低下を最小限にとどめるためにも，胸腔鏡補助下非定型的肺区域切除術は有用であると考えられた．