Perihilar Research Articles

Variação morfológica no padrão lobar e nas fissuras dos pulmões

Modelo do estudo: Relato de caso. Importância do problema: Lobos e fissuras acessórias nos pulmões podem induzir a erros de interpretação e diagnóstico, além de favorecer a disseminação de patologias como a pneumonia para lobos adjacentes. Dessa forma, a constatação dessas alterações anatômicas pode colaborar em diagnósticos clínicos e procedimentos cirúrgicos. Comentários: Relatamos um caso raro de modificação anatômica nos lobos e fissuras dos pulmões. O pulmão esquerdo exibia um lobo médio acessório e uma fissura horizontal completa. Por outro lado, o pulmão direito apresentava duas fissuras acessórias incompletas situadas inferiormente na face costal do lobo médio. Além disso, observamos que o hilo do pulmão esquerdo continha dois brônquios lobares (superior e inferior), um brônquio lobar acessório e três artérias pulmonares. O conhecimento das variações anatômicas aqui relatadas é fundamental, pois auxiliam os profissionais da saúde nos diagnósticos e nas decisões terapêuticas e cirúrgicas.

743P - Exploratory analysis based on tumour location and early metabolic tumour response of REACHIN, a randomized double-blinded placebo-controlled phase II trial of regorafenib after failure of gemcitabine/platinum-based chemotherapy for advanced and metastatic biliary tract tumours

BackgroundREACHIN trial met its primary endpoint of improving PFS in patients with biliary tract cancer (BTC) treated with regorafenib (R) as compared to placebo (P): Median (m) PFS for R was 3.0 months (mo) and 1.5mo for P (HR=0.49; 95% CI: 0.29-0.81, p=0.005)1. We exploratory analyzed the benefit of R according to tumor location (TL): intra-hepatic (ICC), extra-hepatic (ECC), gallbladder (GB) or peri-hilar (PH). The early metabolic response (EMR) by treatment was evaluated by FDG PET/CT. MethodsTL were recorded at randomization of 66 patients in REACHIN (NCT02162914). We analyzed mPFS (95%CI) according to TL. EMR was evaluated comparing FDG tumor metabolism at baseline and after 2 weeks of treatment in the 2 arms if there was at least one FDG positive lesion at baseline, with a Tumour/Liver-uptake-ratio ≥1.4 (MIMvista software). ResultsTable743PTableRRRPPPNmPFS (mo)95%CINmPFS (mo)95%CIICC233.01.5–4.9191.51.1–2.1ECC31.40.5-5.361.50.6–4.7GB44.70.0-8.851.60.4-2PH32.61.1-4.530.50.0-3.0mPFS data are summarized in the table For PET study (29 patients, P n=15/R n=14), both ΔSUVmax, ΔMTV and ΔTLG (%change from baseline) show a significant decrease between baseline and FU scan in R (P=0.0151*;0.037**; 0.0056**) as compared to P. Main tumour SUVmax was significantly decreased in R but not in P(P=0.0353* vs 0.5614). Both TLG and MTV significantly increased in the P (p=0.0004***; 0.0002***; ) while a stabilization was observed for R (P=0.3910; 0.2412). There was no relevant treatment’s related impact on the reference-liver-uptake (P=0.381(P); 0.6149(R)). ConclusionsICC location was predominant (64%). mPFS in P arm is similar according to TL. Despite exploratory value and small number of patients per tumor location, R seems superior to P in ICC, GB and PH. Despite limited number of patients, FDG PET/CT seems performant to discriminate EMR in patients treated with R as compared to P. Additional analysis are ongoing to estimate if these EMR also correlate with PFS and OS. Clinical trial identificationNCT02162914. Editorial acknowledgementCUB Hôpital Erasme (Brussels, Belgium). Support from Bayer HealthCare. REACHIN is a BDGO cooperative study. Legal entity responsible for the studyCUB Hôpital ERASME, Brussels, Belgium. FundingBayer Healthcare. DisclosureA. Demols: Honoraria (self), Honoraria (institution), Advisory / Consultancy, Research grant / Funding (self): Bayer Healthcare. All other authors have declared no conflicts of interest. All other authors have declared no conflicts of interest.

P3678Pulmonary artery ablation during open mitral valve surgery for pulmonary artery hypertension: a prospective randomized study

Abstract Purpose Recent investigations of pulmonary artery (PA) ablation into the treatment of idiopathic pulmonary artery hypertension (PAH) have suggested improvement of functional capacity, and hemodynamics. We investigated the impact of PA ablation in patients with PAH due to left heart disease (Dana Point, 2008) scheduled for open-heart mitral valve surgery. Methods Fifty patients aged 52±10 with mitral valve disease complicated severe PAH (mean PAP >40mm Hg) were randomly assigned to mitral valve surgery with or without PA ablation procedure. Eligible criteria: positive reactive test with nitric oxide inhalation (decrease of mean PAP more than 10 mm Hg without decrease of cardiac output). There were no between group differences in preoperative characteristics. Surgical procedure After bypass is establishedthe fibrous fold of pericardiumand the ligamentum arteriosum are dissected out, and the branches of the right and left pulmonary artery are mobilized well out into the hilum of the lungs bilaterally. PA ablation was performed epicardially at the bifurcation of the main PA, and 10 mm distal to the right and left PA's using AtriCure Isolator®multifunctional pen. Serial assessment of echocardiography, right heart catheterization (catheter Swan-Ganz), and 6-min walk test (6MWT) were performed during hospital stay. The primary endpoints were the change of meanpulmonary artery pressure (PAP)and 6MWT. The secondary endpoints were hospital mortality, freedom from PADN-related complication: PA perforation, PA dissection, and PA thrombosis (MDCT assessment). Results There were no early deaths. No procedure-related complications were observed. On first day after surgery patients from ablation group showed significant reduction of mean PAP (from 50.6±5.3to 34.6±9.9 mm Hg, p<0.001), and significant improvement of 6MWT at discharge (from 229±34 m to 475±21 m, p<0.001). On first day after surgery patients from control group also showed significant reduction of mean PAP (from 51.3±6.3to 47.2±8.5 mm Hg, p=0.011), and significant improvement of 6MWT at discharge (from 249±32 m to 335±18 m, p<0.001). Nevertheless, there was significant between group difference in mean PAP on first day after surgery (34.6±9.9 mm Hg, vs 47.2±8.5 mm Hg, p=0.005). Moreover there was significant differences in 6MWT at discharge (475±21 m vs 335±18 m, p=0.002) with benefit to ablation group. Epicardial pulmonary artery ablation Conclusions We report for the first time the effect and superiority of PA ablation on functional capacity and hemodynamics in patients with mitral valve disease complicated PAH. Epicardial PA ablation for the treatment PAH can be effectively and safely performed during open heart surgery. Acknowledgement/Funding None

Division of inferior pulmonary ligament did not impact on the postoperative recovery or recurrence in patients undergoing video-assisted thoracoscopic surgery for primary spontaneous pneumothorax

Background: Division of inferior pulmonary ligament (IPL) after upper lobectomy was reported to prevent air leak. The research purpose is to investigate whether division of IPL for primary spontaneous pneumothorax (PSP) would decrease air leak and recurrence. Methods: Between 2013/10 and 2015/9, all the patients younger than 30 years old in our institution undergoing video-assisted thoracoscopic surgery (VATS) for PSP were included in this study. Patient with odd chart number underwent division of IPL in addition to VATS wedge resection and pleurodesis for PSP, whereas patients with even chart number underwent VATS wedge resection and pleurodesis without division of IPL. The patient’s age, gender, operative time, and recurrence were all recorded. Chest plain films were taken on the postoperative day 1 (POD1), postoperative day 7 (POD7), and two months after discharge to observe residual pleural space. Results: A total of 110 patients were included in this study. The IPL was divided in 51 patients (rIPL group), and preserved in the other 59 patients (control group). The operative time increased in rIPL group slightly without significant difference (rIPL 81.1 verse control 88.4 minutes, P=0.539). The residual pleural space on the follow-up chest X-ray did not differ between these two groups. They both had similar chest tube drainage days (rIPL 2.7 days versus control 3.1 days, P=0.393). During the follow-up period, one patient in rIPL group (2.0%) and three patients (5.1%) in control group had recurrent pneumothorax (P=0.622). Conclusions: Division of IPL for PSP did not provide clinical benefit of reduction air leak or recurrence rate.

Diagnostic imaging in adult non-cystic fibrosis bronchiectasis.

Radiology plays a key role in the diagnosis of bronchiectasis, defined as permanent dilatation of the bronchial lumen. Volumetric thin-section multidetector computed tomography is an excellent noninvasive modality to evaluate bronchiectasis. Bronchiectasis is categorised by morphological appearance. Cylindrical bronchiectasis has a smooth tubular configuration and is the most common form. Varicose bronchiectasis has irregular contours with alternating dilating and contracting lumen. Cystic bronchiectasis is the most severe form and exhibits saccular dilatation of bronchi. Bronchial dilatation is the hallmark of bronchiectasis and is evaluated in relation to the accompanying pulmonary artery. A broncho–arterial ratio exceeding 1:1 should be considered abnormal. Normal bronchi are narrower in diameter the further they are from the lung hila. Lack of normal bronchial tapering over 2 cm in length, distal from an airway bifurcation, is the most sensitive sign of bronchiectasis. Findings commonly associated with bronchiectasis include bronchial wall thickening, mucus plugging and tree-in-bud opacities. Bronchiectasis results from a myriad of conditions, with post-infectious bronchiectasis being the most common. Imaging can sometimes discern the cause of bronchiectasis. However, in most cases it is nonspecific or only suggestive of aetiology. While morphological types are nonspecific, the distribution of abnormality offers clues to aetiology.Key pointsBronchiectasis is a chronic progressive condition with significant disease burden and frequent exacerbations, for which the diagnosis relies on cross-sectional imaging.The major imaging findings include bronchial dilatation, bronchial contour abnormalities and visualisation of the normally invisible peripheral airways.Bronchiectasis is the end result of various conditions, including immunodeficiencies, mucociliary disorders and infections. Imaging is often nonspecific with regard to aetiology but can be suggestive.Distribution of abnormality in the lung offers helpful clues for establishing aetiology.Educational aimsTo review the cross-sectional imaging appearance of bronchiectasis and the common associated findings.To get a sense of how radiology can aid in establishing the aetiology of bronchiectasis.

Development of bile duct cancer as a long-term complication of biliary-enteric anastomosis for benign diseases: a report of five patients

Objective To study the association, clinical presentation, and diagnosis and treatment of bile duct cancer as a late complication of biliary-enteric anastomoses for benign diseases. Methods A retrospective study was carried out on 5 patients and the medical literature was reviewed. Results They were 3 males and 2 females. The average age was (66.0±0.7) years. The average time period was (14.0±6.1) years after biliary-enteric anastomosis. The clinical presentations included right upper quadrant pain, fever, chills and jaundice. CA19-9, CT and MRI were valuable in diagnosis. There were two patients with distal and three patients with perihilar cholangiocarcinomas (type IIIa, n=2, and type IV, n=1). Local resection with lymphadenectomy was carried out in one patient. Another patient underwent pancreaticoduodenectomy. The remaining three patients only underwent percutaneous transhepatic cholangial drainage (PTCD). The 2 patients who underwent surgery died of progressive tumor disease at 8 and 13 months postoperatively. The other three patients who underwent palliative biliary drainage died within 6 months of PTCD. There was no significant difference between the two types of treatment (P>0.05). Conclusions Chronic cholangitis caused by reflux and bacterial infection was properly a predisposing factor leading to late development of bile duct cancer after biliary-enteric anastomosis for benign diseases. Patients treated with biliary-enteric anastomosis should be closely monitored for late development of cholangiocarcinoma. Some procedures such as choledochoduodenostomy and jejunum interposition choledochoduodenostomy should be abandoned because of their poor outcomes and severe complications. Proper indications of biliary-enteric anastomosis should strictly be followed and the Oddi's sphincter should be protected if possible to prevent late development of bile duct cancer. Key words: Biliary tract diseases; Biliary tract surgical procedures; Bile duct neoplasms; Biliary-enteric anastomosis; Postoperative complication; Treatment outcome

Indocyanine green fluorescence-guided thoracoscopic pulmonary resection for intralobar pulmonary sequestration: a case report

BackgroundThe potential complications of pulmonary sequestration are serious and may include recurrent pulmonary infection, hemoptysis, and tumorigenesis. Therefore, the gold standard of treatment has been surgery. Although an adequate boundary between the nonfunctional lung and normal lung is required for the resection of pulmonary sequestration, the boundaries have been conventionally identified intraoperatively with inflation/deflation of the target segment by clamping and unclamping the relevant bronchus. The technique of visualizing the demarcation line based on near-infrared fluorescence imaging with indocyanine green was recently developed.Case presentationA 42-year-old Japanese woman with right Pryce III intralobar sequestration was admitted to our hospital. We planned video-assisted thoracoscopic wedge resection of the right sequestration using near-infrared fluorescence imaging with indocyanine green because of the small volume of the nonfunctional region. The aberrant artery was recognized in the pulmonary ligament; the artery was cut off after ligation. Indocyanine green at 5 mg/body was rapidly injected into the peripheral vein, and the boundary of the sequestration was clearly identified under near-infrared fluorescence imaging.ConclusionNear-infrared fluorescence imaging with indocyanine green is safe and useful for the identification of the boundary of a pulmonary sequestration.

Stem-Branch: A Novel Method for Tracking the Anatomy During Thoracoscopic S9-10 Segmentectomy

Thoracoscopic S9-10 segmentectomies are the most technically challenging anatomic segmentectomies. Because the target vessels and bronchus are commonly variable and deeply located in the lung parenchyma, exposing and correctly identifying them through an interlobar fissure approach or a posterior approach is difficult. We describe a novel method to track the target segmental branches along the stem during single-direction thoracoscopic S9-10 segmentectomy through an inferior pulmonary ligament approach.

Role of poly(ADP-ribose) polymerase-1 on lung ischemia-reperfusion injury in rats: the relationship with autophagy

Objective To evaluate the role of poly(ADP-ribose) polymerase-1 (PARP-1) in lung ischemia-reperfusion (I/R) injury in rats and the relationship with autophagy. Methods Twenty-four clean-grade healthy male Sprague-Dawley rats, aged 8-12 weeks, weighing 200-240 g, were divided into 3 groups (n=8 each) using a random number table method: sham operation group (S group), lung I/R group (I/R group) and lung I/R plus PARP-1 inhibitor PJ34 group (I/R+ PJ34 group). The chest was only opened without clamping the left hilum of lung in group S. Lung I/R injury model was established by clamping the left hilum of lung for 45 min followed by 120 min reperfusion in I/R and I/R+ PJ34 groups.PJ34 10 mg/kg was intraperitoneally injected at 30 min before ischemia in group I/R+ PJ34, while the equal volume of normal saline was injected in S and I/R groups.The rats were sacrificed at the end of reperfusion, and lungs were removed for microscopic examination of the pathological changes (with a light microscope) which were scored and for determination of wet to dry weight ratio (W/D ratio), cell apoptosis (by TUNEL), expression of PARP-1 activity markers (PAR), Bcl-2, Bax, microtubule-associated protein 1 light chain 3 Ⅰ (LC3-Ⅰ), LC3-Ⅱ and Beclin-1 (using Western blot). The apoptosis index, Bcl-2/Bax ratio and LC3-Ⅱ/LC3-Ⅰ ratio were calculated. Results Compared with S group, the W/D ratio, pathological scores, apoptosis index and LC3-Ⅱ/LC3-Ⅰ ratio were significantly increased, the expression of PAR and Beclin-1 was up-regulated, and Bcl-2/Bax ratio was decreased in I/R and I/R+ PJ34 groups (P<0.05). Compared with I/R group, the W/D ratio, pathological scores, apoptosis index, and LC3-Ⅱ/LC3-Ⅰ ratio were significantly decreased, the expression of PAR and Beclin-1 was down-regulated, and Bcl-2/Bax ratio was increased in I/R+ PJ34 group (P<0.05). Conclusion PARP-1 activation is involved in lung I/R injury in rats, and the mechanism may be related to increasing autophagy and inducing cell apoptosis. Key words: Poly(ADP-ribose) polymerases; Lung; Reperfusion injury; Autophagy

The pattern of lymph node metastasis and prognostic factors analysis of Siewert type II adenocarcinoma of esophagogastric junction

Objective To investigate the pattern of lymph node metastasis and analyze prognostic factors of Siewert type Ⅱ adenocarcinoma of esophagogastric junction (AEG). Methods The retrospective case-control study was conducted. The clinicopathological data of 368 patients with Siewert type Ⅱ AEG who were admitted to Tianjin Medical University Cancer Institute and Hospital from June 2010 and November 2015 were collected. There were 323 males and 45 females, aged from 35 to 80 years, with an average age of 64 years. Of 368 patients, 209 underwent left transthoracic surgery, 112 underwent thoracoabdominal surgery, and 47 underwent Ivor-Lewis surgery. Observation indicators: (1) total lymph node metastasis and metastasis of various lymph node stations; (2)follow-up and survival; (3)prognostic factors analysis; (4) influencing factors affecting thoracic lymph node metastasis. Follow-up using outpatient examination and telephone interview was performed to detect survival of patients up to November 2018. Measurement data with skewed distribution were represented as M (range). Count data were represented as absolute number or percentage. The survival time and rate were calculated using the Kaplan-Meier method. The univariate and multivariate analyses were done by the COX proportional hazard model. Results (1) Total lymph node metastasis and metastasis of various lymph node stations: the total lymph node metastasis rate was 66.58%(245/368) in 368 patients. The metastasis rates of abdominal lymph nodes, thoracic lymph nodes, lower mediastinal lymph nodes, and upper mediastinal lymph nodes were 65.49%(241/368), 12.77%(47/368), 12.23%(45/368), and 1.09%(4/368), respectively. The order of metastasis rate of various lymph node stations from high to low was 51.99%(170/237) of No.7 left gastric artery, 34.23%(89/260) of No.1 right paracardial region, 33.88%(83/245) of No.2 left paracardial region, 28.91%(85/294) of No.3 lesser curvature, 27.10%(29/107) of No.11 splenic artery, 19.75%(16/81) of No.9 celiac trunk, 15.25%(36/236) of No.E8Lo lower paraesophageal region, 11.94%(16/134) of No.4 greater curvature, 11.76%(6/51) of No.E8M middle paraesophageal region, 11.11%(10/90) of No.8 common hepatic artery, 4.65%(4/86) of No.E9L left inferior pulmonary ligament and 3.39%(2/59) of No.E7 subcarinal region. (2) Follow-up and survival: of the 368 patients, 309 were followed up for 1-103 months, with a median follow-up time of 38 months. The survival time of 309 patients was 0.7-101.9 months, and the median survival time was 35.9 months. During the follow-up, the postoperative 1-, 2-, 3-year overall survival rates were 85.9%, 68.6%, and 58.7%, respectively. (3) Prognostic factors analysis. Results of univariate analysis showed that tumor differentiation degree, presence of thoracic lymph node metastasis, number of metastatic lymph nodes, T staging, tumor diameter, and length of esophageal invasion were associated factors affecting prognosis of patients (χ2=8.776, 26.582, 46.057, 18.679, 22.460, 9.158, P<0.05). Results of multivariate analysis showed that presence of thoracic lymph node metastasis, number of metastatic lymph nodes, T staging, and tumor diameter were independent influencing factors for prognosis of patients [odds ratio (OR)=1.699, 1.271, 1.422, 1.238, 95% confidence interval: 1.102-2.621, 1.019-1.481, 1.090-1.856, 0.971-1.481, P<0.05]. (4) Influencing factors affecting thoracic lymph node metastasis: results of univariate analysis showed that tumor diameter, length of esophageal invasion, number of lymph lodes harvested in thorax were related factors for thoracic lymph node metastasis (χ2=5.129, 43.140, 10.605, P<0.05). Results of multivariate analysis showed that length of esophageal invasion ≥2 cm, number of lymph lodes harvested in thorax ≥4 were independent risk factors for thoracic lymph node metastasis (OR=6.321, 1.097, 95% confidence interval: 2.982-13.398, 1.026-1.173, P<0.05). Conclusion Lymph node metastasis of Siewert type Ⅱ AEG spreads two regions, mainly at abdominal lymph nodes, followed by the thoracic lymph nodes. Presence of thoracic lymph node metastasis, number of metastatic lymph nodes, T staging, and tumor diameter are independent influencing factors for prognosis of patients. Presence of thoracic lymph node metastasis indicates poor prognosis of patients. Length of esophageal invasion ≥2 cm and number of lymph lodes harvested in thorax ≥4 are independent risk factors for thoracic lymph node metastasis. Key words: Esophagogastric junction neoplasms; Adenocarcinoma of esophagogastric junction; Siewert Ⅱ type; Thoracic lymph node metastasis; Esophageal invasion; Prognosis

An exploratory analysis based on tumor location of REACHIN, a randomized double-blinded placebo-controlled phase II trial of regorafenib after failure of gemcitabine and platinum-based chemotherapy for locally advanced (nonresectable) and metastatic biliary tract tumors.

e15622 Background: The REACHIN trial met its primary endpoint of improving PFS for patients with biliary tract cancer (BTC) treated with regorafenib (R) as compared to placebo (P): Median (m) PFS for R was 3.0 months (mo) (95% CI: 2.3-4.9) and 1.5 mo (95% CI : 1.2-2.0) for P with an HR= 0.49 (95% CI: 0.29-0.81), p=0.005 (Demols A et al, ASCO-GI 2019, Abstr 345). We exploratory analyzed the benefit of R according to tumor location: intra-hepatic (ICC), extra-hepatic (ECC), gallbladder (GB) or peri-hilar (PH). Methods: Tumor locations were recorded at randomization of patients in REACHIN (NCT02162914), a multicenter double-blinded P-controlled randomized phase II study to evaluate the safety and efficacy of R in patients with locally advanced (non resectable) and metastatic histologically proven BTC, progressing after gemcitabine-platinum. We analyzed mPFS according to tumor location and their respective 95% CI. Results: 66 patients were randomized and the mPFS data are summarized in the table. Conclusions: Most of the patients had ICC location (64%). The mPFS in the P arm is similar according to the tumor location. Despite its exploratory value and the small number of patients per tumor location, R seems superior to P in ICC, GB and PH. Data in ECC are not conclusive. Additional biomarkers (FGFR, NGS analysis) are ongoing and will be presented at the meeting. Clinical trial information: NCT02162914. [Table: see text]

Role and related mechanism of resolvin D1 in lung ischemia reperfusion injury in rats

Objective: To investigate the role and related mechanism of resolvin D1 (RvD1) in lung ischemia-reperfusion injury (LIRI) in rats. Methods: Forty male Sprague-Dawley rats, 7-8 weeks, weighing 220-280 g, were divided into 4 groups using a random number table method: sham operation group, lung ischemia reperfusion control group, normal saline group, and RvD1 group. The rat model of LIRI was produced by 45 min of occlusion of the left hilum of lungs followed by 150 min reperfusion. In sham group, no blocking of the left hilum of lung after thoracotomy; Normal saline 2 ml/kg and RvD1 100 μg/kg were injected respectively at 10 min of reperfusion in normal saline group and RvD1 group. Blood samples were collected from the femoral vein for determination of interleukin (IL)-6, tumor necrosis factor (TNF)-α, soluble inter-cell adhesion molecules (sICAM-1) concentrations at 150 min of reperfusion. The rats were sacrificed after collection of blood samples and then lung tissues were taken for observation of the pathological changes and for measurement of lung wet/dry weight ratio (W/D). The the contents of malondialdehyde (MDA), monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-2 and the activity of myeloperoxidase (MPO) in lung tissues were determined. The protein relative expression of nuclear factor (NF)-κB in lung tissues was detected by Western blot. Lung tissue cell apoptosis was detected with TUNEL method. Results: The plasma level of IL-6, TNF-α, sICAM-1 in normal saline group and RvD1 group were significantly higher than those in the Sham group [(110±7), (100±4) vs (72±3) ng/L, (151±8), (153±6) vs (104±5) ng/L, (2 690±133), (2 760±167) vs (1 953±125) ng/L]. Besides, NF-κB protein relative expression level of lung tissues up-regulated [(0.681±0.033), (0.664±0.024) vs (0.292±0.011)] (all P<0.05). The W/D, apoptosis index, MDA, MCP-1, MIP-2 contents and MPO activity in lung ischemia reperfusion control group, normal saline group and RvD1 group were significantly higher than those in the Sham group [(5.92±0.31), (5.85±0.24), (5.06±0.08) vs (4.14±0.10), (32.9±1.5)%, (31.9±1.3)%, (17.7±1.8)% vs (8.1±0.6)%, (72.1±2.3), (66.7±3.7), (34.0±1.4) vs (22.0±0.8) nmol/mg, (3.99±0.28), (3.86±0.25), (2.66±0.16) vs (1.47±0.17) pg/mg, (9.45±0.53), (9.68±0.62), (7.62±0.22) vs (4.70±0.41) pg/mg, (3.01±0.18), (2.92±0.19), (1.58±0.11) vs (0.98±0.07) U/g] (all P<0.05). The plasma levels of the cytokines mentioned above, the W/D, the apoptosis index, MDA, MCP-1, MIP-2 contents and MPO activity in RvD1 group were significantly lower than those in the lung ischemia reperfusion control group [(63±4) vs (110±7) ng/L, (90±8) vs (151±8) ng/L, (1 835±182) vs (2 690±133) ng/L, (5.06±0.08) vs (5.92±0.31), (17.7±1.8)% vs (32.9±1.5)%, (34.0±1.4) vs (72.1±2.3) nmol/mg, (2.66±0.16) vs (3.99±0.28) pg/mg, (7.62±0.22) vs (9.45±0.53) pg/mg, (1.58±0.11) vs (3.01±0.18) U/g]. Besides, NF-κB protein relative expression level of lung tissues down-regulated [(0.313±0.012) vs (0.681±0.033)] (all P<0.05). Inflammatory cell infiltration in LIRI groups increased significantly, while it was significantly reduced in RvD1 group. Conclusion: RvD1 can effectively alleviate the tissue damage caused by lung ischemia-reperfusion through down-regulating NF-κB expression, relieving inflammatory reaction and oxidative stress, reducing apoptosis in rats.

Accessory Left Lung Fissure with Rare Branching Pattern of Bronchial Tree

Pulmonary fissures separate bronchopulmonary segments and delineate lungs into lobes Anatomical variation of these fissures lie on a continuum from completely fused lobes to accessory fissures in about 17.5% of right and 2% of left lungs. Hilar variations in the bronchial tree and vasculature can also be seen in lobar abnormalities.A routine dissection of an 83‐year‐old male cadaver showed an accessory fissure in the left lung. The hilum of the lung was further dissected for visualization of the bronchial tree and vasculature to explore mediastinal relationships and bronchopulmonary segments. Photographs were taken after dissection. The completeness of the accessory fissure and position of the pulmonary artery were classified using the Craig and Walker Scale.An accessory horizontal fissure forming a complete visceral cleft divided the superior and inferior lingular bronchopulmonary segments of the left lung. However, the fissure did not extend into the hilum at its base and may be classified as a Grade 2 fissure, a “complete visceral cleft but parenchymal fusion at the base.” While the pulmonary artery was positioned normally with reference to oblique fissure, the main and superior lobar bronchus showed variant branching pattern. The left main (primary) bronchus gave rise to the superior and inferior lobar (secondary) bronchi prior to entering the hilum. A normal division of the superior lobar bronchus was observed anterior to the pulmonary artery. The lingular branch of the superior lobar bronchus trifurcated into a rare accessory posterior segmental bronchus in addition to the normal superior and inferior segmental (tertiary) bronchi. The superior and inferior lingular bronchopulmonary segments separated by the accessory fissure were supplied by superior and inferior segmental bronchi, respectively, while the rare accessory posterior segmental bronchus supplied the base of the accessory fissure. The inferior lobar (secondary) bronchus showed normal division and was situated posterior to the pulmonary artery in the hilum. The mediastinal relationships showed the left pulmonary artery posterosuperior instead of anterosuperior to the main bronchus. No cardiac abnormalities were observed.Fewer structural abnormalities have been reported in the left lung in comparison to the right. Bilateral isomerism of the lungs is often associated with heterotaxia, wherein other structures in the chest and abdomen are also altered. In this case, while the left lung had two fissures similar to a right lung, there is no evidence of heterotaxia, suggesting that the abnormality arose from lung bud branching unilaterally during pulmonary development. Knowledge of possible accessory fissures and variant segmental bronchial branching is of clinical importance in understanding the pathological conditions, particularly for radiologists conducting imaging studies and pulmonologists and surgeons conducting bronchoscopies, biopsies and balloon bronchoplasties to place airway stents and lobectomies.Support or Funding InformationSupport from Touro College of Osteopathic Medicine.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Clinical observation of persistent cough after thoracoscopic lobectomy for preserved inferior pulmonary ligament in video-assisted thoracic surgery

Clinical observation of persistent cough after thoracoscopic lobectomy for preserved inferior pulmonary ligament in video-assisted thoracic surgery

Surgical management of pulmonary aspergillosis in pediatric population

IntroductionAspergillosis is an invasive infection that affects mainly immunocompromised patients, and the lung is the most common site of infection. We reviewed our experience with the surgical management of pulmonary aspergillosis (PA) in pediatric population at a tertiary care institution. MethodsA retrospective chart review was conducted for pediatric patients (<16 years) who were managed for PA over the period from January 2001 to December 2016. Demographic, clinical, and outcome data were retrieved, and descriptive data were generated. ResultsEighty patients had microbiologically-proven PA over the period of the study, and 38 of them (48%) had a surgical intervention during their management. Among the surgical group, there were 19 males and 19 females with a mean age of 9.4 years (0.5–16). Thirty-five patients (92%) were in an immunocompromised state (10 of them have had bone marrow transplant), 2 patients had cystic lung disease, and 1 had scleroderma. All had fever and respiratory symptoms at presentation and received systemic antifungal medications. All had Computerized tomography (CT) scan examinations which showed features suggestive of the disease. Surgical procedures included lung biopsy in 13 patients (34%), segmentectomy in 12 patients (32%), lobectomy in 8 patients (21%), debridement/cavernostomy in 3 patients (8%), and 2 patients had pneumonectomy (5%). Histopathological examination revealed invasive fungal infection in 20 patients (53%) and aspergilloma in 18 (47%). Eleven patients (29%) died owing to a combination of fungal infection and the underlying disease. Three other patients, not included in the surgical series, died secondary to severe pulmonary hemorrhage while waiting for surgery. All had cavitation on CT scan near the hilum of the lung. ConclusionsPulmonary aspergillosis is a severe invasive infection with a significant mortality. Early surgical intervention is recommended in patients who do not improve on antifungal medication, especially in those with cavitating lesions, in order to improve outcome. Type of studyCase series. Level of evidenceIV.

Effect of inferior pulmonary ligament division on residual lung volume and function after a right upper lobectomy.

The requirement to divide an inferior pulmonary ligament (IPL) during an upper lobectomy has not been standardized. We evaluated the influence of the division of an IPL after a lobectomy of the right upper lobe. We evaluated 52 patients with lung cancer who underwent a video-assisted thoracoscopic lobectomy of the right upper lobe at Asan Medical Center between January 2011 and April 2014. These cases were stratified by division of the IPL or not, i.e. a preservation group (group P, n = 21) and a division group (group D, n = 31). The angle between the bronchus intermedius and the right middle lobe bronchus and the lung volume were measured using computed tomography. The results of the pulmonary function tests and the prevalence of complications were also reviewed. The prevalences of atelectasis (P = 0.538), dead space (P = 0.084) and pleural effusion (P = 0.538) were not statistically different. The postoperative volumetric change of the right middle lobe (group P, -27 ± 97 ml; group D, -29 ± 111 ml; P = 0.950) and of the right lower lobe (group P, 397 ± 293 ml; group D, 335 ± 294 ml; P = 0.459) did not show statistical differences. The change in the bronchial angle was not statistically different between the groups (group P, -26.3 ± 13.7°; group D, -26.7 ± 13.6°; P = 0.930). The patients in group D experienced a greater loss in forced vital capacity than those in group P (group P, -0.16 ± 0.26 l; group D, -0.42 ± 0.33 l; P = 0.007), but the loss in the forced expiratory volume in 1 s was not significant (P = 0.328). An IPL division does not produce significant differences in lung volume, bronchial angle change or prevalence of complications other than loss of forced vital capacity.

Clinical outcomes of preoperative endoscopic nasobiliary drainage versus percutaneous transhepatic biliary drainage for patients with perihilar cholangiocarcinoma

Objective To compare the clinical outcomes of endoscopic nasobiliary drainage (ENBD) versus percutaneous transhepatic biliary drainage (PTBD) in patients with perihilar cholangiocarcinoma. Methods This retrospective case-control study was conducted on 55 patients with perihilar cholangiocarcinoma who were treated by of hepatobiliary and pancreatic surgeons at the Nanjing Drum Tower Hospital between December 2010 and August 2017. Results There was no significant difference in the effectiveness of the two drainage methods (P>0.05). Morbidity after drainage was significantly higher in the ENBD group than the PTBD group (86.7% vs 28.0%, P 0.05). Abdominal infection after surgery was more common in the PTBD group than the ENBD group (64.3% vs 26.3%, P<0.05). Conclusion As PTBD caused catheter tract tumor implantation and increased the incidence of abdominal infection after surgery, ENBD was recommended for patients with perihilar cholangiocarcinoma treated in a tertiary medical center. Key words: Perihilar cholangiocarcinoma; Biliary drainage; Endoscopic nasobiliary drainage; Percutaneous transhepatic biliary drainage

Difficulties and countermeasures of diagnosis and treatment of biliary dilatation

The pathogenesis of biliary dilatation is unclear and the preoperative evaluation of pancreaticobiliary junction type is still difficult. The indication of minimally invasive surgery is limited. Diagnosis and treatment of gestational biliary dilatation and reoperation of biliary dilatation are two tricky problems. There are two dilemmas in the treatment of biliary dilatation, including the balance between radical resection of pathological bile ducts and organ reservation, as well as balance between radical resection of pathological bile ducts and surgical safety. The most difficult regions of diagnosis and treatment lie in the hilar dilated bile duct and dilated bile duct in the pancreatic segment. Dong′s classification simplifies the classification of extrahepatic bile duct dilatation and subdivides the classification of intrahepatic bile duct dilatation on the basis of Todani classification. It highlights the difficulties of treatment and provides more accurate basis for choosing appropriate method according to the classification. The therapeutic goals of biliary dilatation are the radical excision of pathological bile duct, removal of the secondary lesions and reconstruction of excellent cholangiojejunostomy. The principle of surgical procedure choice is choosing appropriate method according to the classification. Perihilar surgery technique and pancreatic door plate descending technique can be used to deal with the dilated bile ducts at hilar and pancreatic segment on the basis of accurate evaluation in order to improve the thoroughness and security of pathological bile duct resection. Not only short-term complications such as postoperative bile leakage and pancreatic leakage require management, but radical resection of lesion and long-term life quality of patients should be paid more attention. Key words: Biliary dilatation; Perihilar surgery technique; Dong′s classification; Pancreatic door plate descending technique

The “loop” technique for primary spontaneous pneumothorax: a retrospective study of 18 patients

Background: Primary spontaneous pneumothorax (PSP) is a well-known disease but with multiple different surgical approaches. The objective of our study is to present the results of an innovative minimal uniportal approach for patients with such a disease. This will be able to reduce postoperative pain simultaneously considering the cosmetic problems of otherwise ‘healthy’ patients. Methods: We retrospectively evaluated the surgical results of 18 patients who underwent single incision thoracoscopic surgery (SITS) using a loop at our institution between January 2015 and August 2016. Single access of 20 mm was done at the level of the 8th intercostal space. We used a ‘loop’ of a non-absorbable braided suture inserted through the IV intercostal space to isolate and suspend any dystrophic area to resect. In every patient, the pulmonary ligament was dissected and pleurodesis done with pleural abrasion. Results: We had no complications after SITS. The mean operative time for SITS was 55±7.36 (standard deviation) minutes. Usually, the chest tube is removed in the 2nd postoperative day, and the patient discharged the day after. There were no conversions from SITS to three-port VATS or thoracotomy. Nobody reported chronic pain and paraesthesia. No patients had an ipsilateral recurrence of pneumothorax in the 2 years after surgery. Conclusions: The operation we propose is safe and easily reproducible. Considering the small number of patients, this technique offers excellent results regarding the duration of recovery, postoperative pain and paraesthesia, without increasing the risks of complications for the patient and the costs of surgery.

Recurrence of Extramedullary Plasmacytomas Involving Lymph Nodes and Pancreas Revealed by 68Ga-DOTATATE and 18F-FDG PET/CT

A 40-year-old man with history of extramedullary plasmacytoma in nasal cavity presented with right submandibular mass for 3 months. F-FDG PET/CT demonstrated mild radioactivity in the right submandibular mass, pancreatic mass, and lymph nodes in the abdomen and left hilum of the lung. To differentiate from pancreatic neuroendocrine tumor, Ga-DOTATATE PET/CT was performed. The above lesions were TATE avid, and additional lesions with intense radioactivity were also detected in the right internal mammary node and intrapericardial node. Finally, biopsy of the right submandibular mass confirmed recurrence of extramedullary plasmacytoma.