Perihilar Research Articles

A Rare Case of Interlobar Pneumothorax

BACKGROUND: Pneumothorax is a severe medical condition characterized by the collection of air in one or several spaces of the pleura. A rare subtype of pneumothorax where air is restricted in interlobar pleural space, mostly due to the previous fibrous pleural adhesions, is known as interlobar pneumothorax. CASE PRESENTATION: We present a rare case of a 58-year-old female admitted to the emergency department due to difficulty on breathing, hemoptysis, and discomfort in the right anterior axillary line, which worsened with inspiration and was associated with breathlessness during physical activity. The diagnosis was confirmed by thoracic multi slice computed tomography (MSCT), showing that air was located between the middle and lower lobes of the right lung , measuring 7 × 5 × 2.5 cm (transversal × oblique cranio-caudal × antero-posterior), representing interlobar pneumothorax. DISCUSSION: Cases of interlobar pneumothorax need to be carefully differentiated and evaluated, while skin folds, overlapping breast margin, interlobar fissure, bullae in the apices, pneumomediastinum, pneumopericardium, inferior pulmonary ligament air collection, pneumatocele, and air collection in the intrathoracic extrapleural space, can mimic pneumothorax and make diagnosing very challenging.

Right pneumonectomy for primary large acinic cell carcinoma (AciCC) with severe mediastinal deviation: a case report and literature review

BackgroundPrimary lung acinic cell carcinoma is very rare. Here we report a young female patient who suffered the largest primary lung acinic cell carcinoma with severe mediastinal deviation which has never been reported before. We also reviewed data and features of 20 previously reported cases of primary lung acinic cell carcinoma who underwent lobectomy.Case presentationA 27-year-old female patient presented with recurrent coughing and hemoptysis for more than 10 years came to our hospital. A chest computed tomography (CT) showed a giant space-occupying lesion in the hilum of right lung. After a thorough and detailed preoperative examination, the patient then was performed a radical right pneumonectomy with mediastinal lymph node dissection. The size of the tumor was about 8.6 × 4.5 × 4.4 cm. The pathological results demonstrated a primary acinic cell carcinoma of right lung. The immunohistochemistry of the tumor showed AE1/AE3 (+), Ki-67 (2% +), CK7 (+), Vimentin (+), CK19 (+), α1-ACT (+), AB-PAS (+), S-100 (−), TTF-1 (−). The patient was discharged less than 2 weeks after the operation. So far, the patient has been followed-up for 2 years, and no evidence of tumor recurrence or metastasis was observed.ConclusionsThe primary acinic cell carcinoma of lung in this case is the biggest one ever reported and also the first case treated with radical right pneumonectomy. In addition, the patient had a very rare condition of severe mediastinal deviation at the same time. After surgical treatment, the patient recovered uneventfully and had stable disease without recurrence and metastasis after 2 years of follow-up. This case together with the reported case indicate that primary acinic cell carcinoma of lung is of low malignancy, the prognosis and therapy effect of surgical treatment are relatively satisfactory.

S2134 Pulmonary Artery Sling—An Extremely Rare Etiology of Dysphagia

Introduction: Pulmonary artery sling (PAS) is a rare anomaly created when the left pulmonary artery originates from the posterior aspect of the right pulmonary artery and courses over from right to left, posterior to the trachea or carina and anterior to the esophagus, to reach the hilum of the left lung. While coursing, it can compress the trachea or the esophagus resulting in airway or esophageal obstruction. Case Description/Methods: 43-year-old man with history of Down’s syndrome was evaluated for esophageal dysphagia for solid food of 2-month duration. EGD was unrevealing except for mild distal esophagitis. Mid and distal esophageal biopsies were negative for eosinophilic esophagitis. Barium esophagogram revealed extrinsic impression on the right side of esophagus just inferior to the aortic arch. CT thorax revealed showed presence of left pulmonary artery (PAS) corresponding to the above-mentioned extrinsic impression seen on esophagogram. Due to complexity and high mortality associated with the required corrective surgery it was decided to manage this condition conservatively with dietary modifications. Discussion: Vascular rings are congenital anomalies that can present with a variety of pulmonary and gastroesophageal symptoms. PAS is a rare vascular anomaly first described by Glaevecke and Doehle in 1897. PAS can be associated with congenital cardiac anomalies like ASD, VSD or PDA or airway anomalies like tracheal stenosis. Majority of patients are symptomatic and 2/3rd of patients presents within their first 2 months of life mainly with respiratory symptoms of stridor, respiratory distress, cyanosis, wheezing, and/or pneumonia. Presentation in adulthood is extremely rare as only one other case of adult-onset dysphagia caused by PAS has been reported in English literature in 1966 by Dumler. Arteriosclerotic dilatation of the anomalous pulmonary artery can account for late onset of dysphagia in previously asymptomatic individuals. Corrective surgery is mainstay of treatment for life-limiting symptoms after failure of conservative management.Figure 1.: Cartoon depiction of Pulmonary sling (A), Esophagram (B), CT (C, D) showing aberrant pulmonary artery.

This video demonstrates, step by step, a right thoracoscopic S9+10 segmentectomy through a subxiphoid approach combining both interlobar fissure and inferior pulmonary ligament approaches, on the basis of 3D-CT reconstruction and fluorescence imaging

This video demonstrates, step by step, a right thoracoscopic S9+10 segmentectomy through a subxiphoid approach combining both interlobar fissure and inferior pulmonary ligament approaches, on the basis of 3D-CT reconstruction and fluorescence imaging

Inferior Pulmonary Ligament Division May Be Unnecessary during Left Upper Lobectomy: Effects on Lung Volume, Bronchial Angle and Bronchial Tortuosity.

The benefits of dissecting inferior pulmonary ligament (IPL) during upper lobectomy using video-assisted thoracoscopic surgery (VATS) for early-stage lung cancer remains controversial. This study evaluates the effect of IPL dissection by comparing the lung volume, bronchial angle, and bronchial tortuosity of the left lower lobe (LLL) during VATS upper lobectomy. Medical records of all patients who underwent VATS left upper lobectomy for early-stage lung cancer were evaluated. Patients were divided into group P (preservation) and group D (dissection). Pre- and post-surgery lung volumes, bronchial angles (angle 1: axial angulation; angle 2: vertical angulation), and bronchial tortuosity (curvature index of the left main bronchus) were measured using computed tomography images for comparison. Forty patients were included in each group. Patient characteristics such as age, gender, body mass index, and smoking status, and preoperative lung volume, bronchial angles, and tortuosity were not significantly different between the two groups, and there was no statistically significant difference in the axial and vertical angulations; however, the change in pre- and postoperative bronchial tortuosity (0.03 ± 0.03 vs. 0.06 ± 0.03) and lung volume (−558.1 ± 410.0 mL vs. −736.3 ± 382.7 mL) showed a significant difference (p < 0.001 and p = 0.04, respectively). Preservation of IPLs during left upper lobectomy may be beneficial for LLL expansion and induces less movement and positional change in the left main bronchus.

Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type Ⅱ adenocarcinoma of the esophagogastric junction

Objective: Surgical operation is the main treatment for advanced adenocarcinoma of esophagogastric junction (AEG). Due to its special anatomic location and unique lymph node reflux mode, the surgical treatment of Siewert II AEG is controversial. Lower mediastinal lymph node dissection is one of the most controversial points and a standard technique has not yet been established. This study is aim to explore the safety and feasibility of five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection for Siewert type II AEG. Methods: A descriptive case series study was conducted. The intraoperative and postoperative data of 25 patients with Siewert type II AEG who underwent five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph node dissection in Guangdong Provincial Hospital of Traditional Chinese Medicine from January 2019 to April 2021 were retrospectively analyzed. Five-step maneuver was as follows: In the first step, the subcardiac sac was exposed; the right pulmonary ligament lymph nodes and the anterior thoracic paraaortic lymph nodes were dissected cranial to inferior pericardium, left to left edge of thoracic aorta. In the second step, the left diaphragm was opened, and a 12 mm trocar was placed through the 6-7 rib in the left anterior axillary line. The supra-diaphragmatic nodes were dissected through the thoracic operation hole. In the third step, the left inferior pulmonary ligament was severed. The anterior fascia of thoracic aorta was incised to join the anterior space of thoracic aorta formed in the first step and then the lymphatic tissue was dissected upward until the exposure of left inferior pulmonary vein. In the fourth step, the posterior pericardium was denuded retrogradely from ventral side to oral side to the level of left inferior pulmonary vein, right to right pleura, and then the right pulmonary ligament lymph nodes were completely removed. In the fifth step, the esophagus was denuded, and the esophagus was transected 5 cm above the tumor using a linear stapler to complete the dissection of lower thoracic paraesophageal lymph nodes. Results: Operations were successfully completed in 25 patients without conversion, intra-operative complication and perioperative death. Total gastrectomy was performed in 19 cases and proximal gastrectomy in 6 cases. The mean operative time was (268.7±85.6) minutes, the mean estimated blood loss was (90.4±44.2) ml, the mean time of lower mediastinal lymph node dissection was (38.6±10.3) minutes, and the mean harvested number of lower mediastinal lymph node was 5.9±2.9. The length of esophageal invasion was >2 cm in 7 cases and ≤ 2 cm in 18 cases. Eight patients (33.0%) had lower mediastinal lymph node metastasis, including 3 cases with esophageal invasion >2 cm and 5 cases with esophageal invasion ≤ 2 cm. The mean time to postoperative first flatus was (5.5±3.1) days. The average time of postoperative thoracic drainage was (5.9±2.9) days. The mean hospital stay was (9.7±3.1) days. Two patients (8.0%) developed postoperative grade IIIa complications according to the Clavien-Dindo classification, including 1 case of pancreatic fistula and 1 case of pleural effusion, both of whom were cured by puncture drainage. Conclusions: Five-step maneuver of transthoracic single-port assisted laparoscopic lower mediastinal lymph nodes dissection for Siewert type II AEG is safe and feasible. Which can ensure sufficient lower mediastinal lymph node dissection to the level of left inferior pulmonary vein.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps.

Vein step. Description: Pulmonary ligament division. The common basal vein is dissected, encircled with a tape and divided using an angled vascular endostapler.

Vein step. Description: Pulmonary ligament division. The common basal vein is dissected, encircled with a tape and divided using an angled vascular endostapler.

The impact of dissection of station 9 on survival and the necessity of pulmonary ligament division during upper lobectomy for lung cancer

Background We conducted this study to investigate the need for dissection of station 9 lymph nodes during upper lobectomy for non-small-cell lung cancer (NSCLC) and to find out the operative results of inferior pulmonary ligament division. Methods A total of 840 patients who underwent upper lobectomy for NSCLC between January 2007 and June 2020 were evaluated retrospectively. The patients were separated into two groups – those having undergone lymph node dissection of station 9 and inferior pulmonary ligament dissection (Group I) and those who did not (Group II). In these groups, the prognostic value of station 9 lymph nodes and postoperative effects (drainage time, prolonged air leak, dead space and length of hospital stay) of ligament division or preservation were analyzed. Results The number of patients with station 9 lymph node metastasis was only one (0.1%) and that was multi-station pN2 disease. Station 9 lymph nodes were found in 675 (80.4%) patients, while 22 (2.6%) patients had no lymph nodes in the dissected material. In the other 143 (17%) patients, the inferior pulmonary ligament and station 9 were not dissected. While 5-year survival was 64.9% in 697 patients of Group I, it was 61.3% in 143 patients of Group II (p = 0.56). There was no statistically significant difference between the groups in postoperative effects of ligament division or preservation. Conclusions In upper lobectomies, status of station 9 does not have a significant impact on patients' survival and lymph node staging. Additionally, preservation or division of the inferior pulmonary ligament has no significant advantage or disadvantage.

Thoracoscopic radical esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach: A single-center retrospective study of 30 cases.

To evaluate the necessity, safety, and feasibility of left inferior pulmonary ligament lymphadenectomy during video-assisted thoracic surgery (VATS) radical esophagectomy via the right thoracic approach.Thirty patients (20 men, 10 women) with thoracic esophageal squamous cell carcinoma (ESCC) were recruited for this study. The patients’ age ranged from 50 to 80 years, with an average age of 66.17 ± 7.47 years. After the patients underwent VATS radical esophagectomy and left inferior pulmonary ligament lymph node dissection (LIPLND) via the right thoracic approach, the operative outcomes included operative time, length of hospital stay, postoperative complications, number of lymph nodes removed, and postoperative pathologic results were evaluated.There were no massive hemorrhages of the left inferior pulmonary vein during the operation. The operative time of LIPLND was 8.67 ± 2.04 minutes, and the length of postoperative hospital stay was 12.23 ± 2.36 days. The postoperative complications included 2 cases of left pneumothorax, 4 pulmonary infection cases, and no chylothorax. Moreover, 68 LIPLNs were dissected, 5 of which were positive, and the degree of metastasis was 7.4%. The postoperative pathologic results showed that 3 cases of LIPLNs were positive, with a metastasis rate of 10.0%. Among them, 2 cases were SCC of the lower thoracic esophagus, and 1 case was SCC of the middle thoracic esophagus, which involved the lower segment.Thoracoscopic esophagectomy combined with left inferior pulmonary ligament lymphadenectomy for esophageal carcinoma via the right thoracic approach will not increase the difficulty of operation, increase the incidence of postoperative complications or prolong the postoperative hospital stay, and can theoretically reduce tumor recurrence. Therefore, we believe that LIPLND is necessary, safe, and feasible and is worthy of clinical popularization and application.

Uniportal Single-Direction Thoracoscopic Right S9 Segmentectomy: Trans-Inferior-Pulmonary-Ligament Approach.

We previously described a three-port single-direction thoracoscopic segmentectomy for the right S9, which is the most challenging anatomic segmentectomy. However, uniportal thoracoscopic surgery has been widely accepted for the therapy of early stage non-small cell lung cancer in the past decade. In this multimedia article, we describe a uniportal thoracoscopic right S9 segmentectomy through an inferior pulmonary ligament approach following a single-direction strategy and using the stem-branch method for segmental structure tracking. The operation went successfully and the patient recovered smoothly. By taking advantage of the stem-branch method, trans-inferior-pulmonary-ligament approach, and single-direction strategy, the uniportal thoracoscopic S9 segmentectomy can be performed successfully through optimization of some technical details.

Epstein-Barr virus infection-related post-transplant lymphoproliferative disorders in transplanted lung: a clinicopathological analysis

Objective: To investigate the clinicpathological characteristics of post-transplant lymphoproliferative disorders (PTLD) in transplanted lung, and to improve its diagnosis and treatment. Methods: The clinicopathological characteristics of PTLD in three transplanted lungs were evaluated at Wuxi People's Hospital Affiliated to Nanjing Medical University from 2014 to 2019. HE, immunohistochemical staining and in situ hybridization were performed. The relevant literature of PTLD was reviewed. Results: All three patients had chronic obstructive pulmonary disease (COPD) before lung transplantation. After receiving both lung transplants, they were all treated with anti-rejection drugs tacrolimus or mycophenolate mofetil, and combined with antiviral and/or rituximab. The time from transplantation to diagnosis of PTLD was four years, seven months, and five months, respectively. Two patients died one month and five months after initial diagnosis, and one patient was alive with no disease after one year. Histologically, all cases were monomorphic B-cell PTLD (diffuse large B-cell lymphoma, unspecified), and the tumor cells were positive for Epstein-Barr virus by in situ hybridization; one of the late-onset patients had herpes simplex virus infection. Conclusions: PTLD in the post-transplant lung tissue shows unique morphology and clinical characteristics, and is closely related to Epstein-Barr virus infection. Patients who receive lung transplantation due to COPD are more susceptible to develop PTLD, while late-onset ones occur more commonly in the hilum of lungs, and the prognosis is relatively poor.

A pulmonary ligament approach for portal robotic segmentectomy of the lateral and posterior basal segments: a case report

BackgroundThoracoscopic segmentectomy of the lateral and posterior basal segments is extremely technically challenging. Appropriate segmentectomy requires exposure and recognition of the branches of the bronchi and pulmonary vessels deep in the lung parenchyma. Although various approaches for these segmentectomies have been reported, the use of a pulmonary ligament approach is rational because it does not require any interlobar separation. Here, we report a successful case of portal robotic segmentectomy of the lateral and posterior basal segments through the pulmonary ligament approach.Case presentationA 60-year-old Japanese man with a history of low anterior resection for rectal cancer was referred to our department because of a lung nodule. His chest computed tomography revealed a 15-mm tumor in the left posterior basal bronchus. Robotic left S9–10 segmentectomy through the pulmonary ligament was performed with five-port incisions.ConclusionsAn extremely technically challenging thoracoscopic segmentectomy of the lateral and posterior basal segments was performed through the pulmonary ligament using a robotic surgical system.

Using the autologous innominate vein as a substitute for pulmonary arteries in a patient with pulmonary atresia and absent pulmonary arteries

BackgroundRepair of the absence of the whole or major parts of pulmonary arteries is a challenge, and the choice of conduit material to reconstruct the pulmonary arteries is under dispute. We used the autologous innominate vein to construct pulmonary arteries.Case presentation lWe present a novel technique using the autologous innominate vein as a free graft in a 6-month-old infant with pulmonary atresia and absence of central pulmonary arteries. Double ductus arteriosus were the only source of perfusion of the lungs. The innominate vein was substituted for the central pulmonary artery between the two lung hila. Total repair by using Contegra graft was performed 9 months later. The patient has been followed for 5 years.ConclusionsThe autologous innominate vein could be used as inter-hilar pulmonary arteries with no calcification and fibrosis in 5-year follow-up.

Contemporary Experience with Paravisceral Aortic Aneurysm (PVAAA) Repair in a Tertiary Center

To describe contemporary outcomes from a single center capable of both complex open and endovascular aortic repair for paravisceral aortic aneurysms (PVAAA). Data on all patients receiving open or endovascular (endo) treatment for aortic aneurysms with proximal extent at or above the renal arteries and distal to the inferior pulmonary ligament (IPL) were reviewed. Coarsened exact matching (CEM) on age, aneurysm type, gender, coronary artery disease (CAD), previous aortic surgery and symptomatic status created balanced cohorts for outcomes comparisons. Between October, 2006 and February, 2018, 194 patients were treated for juxtarenal (40%), pararenal (21%), paravisceral (6%) and Type 4 thoracoabdominal (34%) aortic aneurysms with open (81, 42%) or endo (113, 58%) at a single tertiary center. Endo repairs included renal coverage with a bifurcated graft (2%), unilateral (13%) or bilateral (4%) renal snorkels, Z-fen (15%), multi-branched graft (IDE protocol; 62%) and unique complex configurations (4%). On multivariable analysis, patients selected for open surgery were more likely to be symptomatic, whereas older patients, female patients and those with Type 4 TAAA extent were more often selected for endovascular treatment. Matching based on the significant independent covariates reduced the open and endovascular groups by one-third. Survival at 30 days was 97% for endo and 94% for open repair, 98% for both subgroups when excluding symptomatic cases, and was not different between the matched groups (98% vs 89%; P=0.23). Hospital and ICU stays were longer in open patients (8 vs. 10 days, 2 vs. 4, both P≤0.001). Post-op CVA, MI, lower extremity ischemia, surgical site infections and reoperation were not different between matched groups (all p>0.05), while pulmonary and intestinal complications, as well as grade 1/2 renal dysfunction by RIFLE criteria, were more common after open repair (all P<0.05). Spinal cord ischemia was significantly more frequent in the unmatched Endo group (11% vs. 1%, P=0.02), but this difference was not significant after matching. Composite major aortic complications was no different between treatment groups (unmatched P=0.91, matched P=0.87). Endo treatment resulted in patients more frequently discharged to home (84% vs. 66%, P=0.02). Reintervention after 30 days occurred more frequently in the endo group (P=0.002). Estimated survivals at 1 and 5 years for endo and open are 96% vs. 81% and 69% vs. 81% respectively (Log-rank P=0.57). Contemporary repair of PVAAA demonstrates safe outcomes with durable survival benefit when patients are well-selected for open or complex endovascular repair. We believe these data have implications for off-label device use in the treatment of PVAAA, and that open repair remains an essential option for younger, good risk patients in experienced centers.

The video depicts a three-dimensional interactive quantitative surgical planning inferior pulmonary ligament approach VATS right S9+10 segmentectomy.

The video depicts a three-dimensional interactive quantitative surgical planning inferior pulmonary ligament approach VATS right S9+10 segmentectomy.

Robotic right upper lobectomy: Twelve steps.

Robotic right upper lobectomy: Twelve steps.

Nephrotic syndrome with focal segmental glomerular lesions unclassified by Columbia classification; Pathology and clinical implication.

BackgroundThe Columbia classification is widely used for diagnosis of focal segmental glomerulosclerosis (FSGS). In practice, we occasionally encounter segmental glomerular lesions unclassified as Columbia classification. We analyzed the clinical implication of unclassified segmental lesions comparing with Columbia-classified FSGS.MethodsA retrospective cohort study from 13 local hospitals in Japan. From 172 biopsy cases diagnosed with FSGS or minimal change disease (MCD)/FSGS spectrum with unclassified segmental lesions, adult patients with nephrotic syndrome who received immunosuppressive therapies were included. The cases are classified by pathology, i.e., typical FSGS lesions sufficiently classified into subgroups of Columbia classification: collapsing (COL), tip (TIP), cellular (CEL), perihilar (PH), and not otherwise specified (NOS), and unclassified by the Columbia classification into three subgroups: “endothelial damage,”; “simple attachment,”; and “minor cellular lesion,”. The response to immunosuppressive treatment and 30% decline of eGFR were compared.ResultsAmong 48 eligible cases, all were Japanese, 34 were typical FSGS; 13 TIP, 15 CEL, 6 NOS, and no COL or PH cases. Fourteen were unclassified cases: endothelial damage (n = 6), simple attachment (n = 5), and minor cellular lesion (n = 3). The median age of overall patients was 60 years old and the median of eGFR and urinary protein creatinine ratio was 51.5 mL/min/1.73m2 and 7.35, respectively. They received similar therapeutic regimen. Kaplan-Meier analysis revealed no significant difference in treatment response between typical FSGS and unclassified cases. Evaluating among the subgroups, endothelial damage, simple attachment and minor cellular lesion showed similar treatment response to TIP or CEL. No significant difference was also observed in the 30% decline of eGFR.ConclusionsJapanese adult patients with nephrotic syndrome showing unclassified segmental lesions as Columbia classification may be equivalent clinical impact as Columbia classification of FSGS.

A Fatal Pneumonia due to Coinfection of Pseudomonas putida and Staphylococcus pseudintermedius in a Laboratory Beagle Dog

Background: Pseudomonas putida (P. putida) is widely distributed in the environment, and sometimes caused nosocomial infections in human beings, but no case of infection has been reported in beagle dogs. Staphylococcus pseudintermedius (S. pseudintermedius) is a natural cutaneous bacterium in dogs and occasionally causes purulent infections of the skin and rarely causes pneumonia. Both bacteria are opportunistic pathogens. Dogs, even well-controlled laboratory beagle dogs, maybe infected by the bacterium in certain conditions like this report. In order to provide information and give suggestion to veterinarians involved in dogs study, a complete profile of the coinfection was drawn in this report.Case: It is presented a case of an 8-month-old beagle dog, weighing 6 kg that suffered from coinfection of P. putida and S. pseudintermedius during a treatment of chemotherapy. The animal was confirmed as normal by appearance, physical examination, and laboratory tests before arrival according to the applicable guidelines. After 14-day acclimation period, the animal was administrated with a tyrosinase inhibitor once daily via oral gavage. From Day 8, coughing, decreased activity, hyporeflexia, squinting, shortness of breath (abdominal breathing), and discharge around the nose as well as crackles in the lung and rapid heart rate were noted. Since the poor conditions progressed rapidly and have not been improved by treatment of ceftriaxone and dexamethasone. On Day 9, the animal was euthanized for humanitarian reasons due to rapid progress and poor condition. To define the pathogen, hilar lymph node and thoracic swab were collected for bacteria isolation and purification in special mediums, and at last characterized by Gram staining and 16s rRNA gene sequence analysis and positive PCR-restriction fragment length polymorphism. In clinical pathological examination, an increase in WBC, neutrophils, lymphocytes, monocytes, cholesterol, triglyceride, total protein, globulin, and lactate dehydrogenase, as well as a decrease in RBC, hemoglobin, hematocrit, platelets, sodium ion, chloride ion, and albumin were noted. At necropsy, dark red and enlarged lymph nodes were noted in the hilum of lung, multiple abscesses with yellow pus and multifocal hemorrhage were noted in the lung, and a large amount of frothy yellow fluid were noted in the trachea. In pathological examinations, severe neutrophilic inflammation, diffuse and moderate macrophage aggregation, mild hemorrhage, and moderate alveolar emphysema were noted in the lung, and severe sinusoidal stasis were noted in portal lymph nodes.Discussion: The current case presented a profile of the appearance, treatment, hematological examination, coagulation examination, clinical chemistry, macroscopic and histological changes in the lung. Multiple purulent abscesses, infiltration of neutrophils, macrophage, and hemorrhage, were correlated to the increase in WBC, neutrophils, lymphocytes, and monocytes, and the decrease in RBC, hemoglobin, hematocrit, and platelets. In the coagulation examination, an increase in Fbg concentration was noted. This change may be induced by the coagulase effect of the S. pseudintermedius, yet no effect on PT or APTT was noted, indicating the coagulation function has not been affected. In the clinical chemistry, the increase of creatine kinase and lactate dehydrogenase may indicate tissue cell damages. Significant increase of globulin may be caused by the inflammatory status. In conclusion, the findings in this case indicate that both Pseudomonas putida and Staphylococcus pseudintermedius can induce infections in laboratory beagle dogs under certain conditions, and might result in a fatal pneumonia which could progress very fast within several days.

A novel guiding tube modified from a Foley catheter for endostapling during robot-assisted pulmonary resection.

BackgroundMassive intraoperative bleeding resulted from vascular injury during the dissection of pulmonary vessel in minimally invasive lobectomy is a troublesome and dangerous surgical scenario. It is reported that vascular injury result in 29–45% of incidences of conversion to thoracotomy in minimally invasive pulmonary surgery. In this paper, we introduce a guiding tube created from two-way Foley catheter for robotic pulmonary resection in attempting to avoid vascular injury when passing linear stapler.MethodsFrom July 2018 to June 2019, this guiding method was adopted in patients who underwent robot-assisted thoracoscopic surgery lobectomy. The technical details and short-term outcomes are described in this paper.ResultsA total of 31 patients were successfully treated with robotic pulmonary resection with help of the guiding method presented in this study. The median surgical time was 180 min and the median loss of blood was 100 mL. Only one patient was converted to open thoracotomy for silicoanthracotic lymph nodes adhered in hilum of lung. The median length of hospital stay was 5 days. There was no mortality in 30 days after hospital discharge.ConclusionsThis modified Foley catheter seems to be a promising guiding method to avoid vascular injury when passing linear stapler in robotic pulmonary resection.