Partial Lung Resection Research Articles

Open Window Thoracostomy for Pleural Empyema Complicating Partial Lung Resection

Although an open-window thoracostomy (OWT) represents the ideal method for drainage of postpneumonectomy empyema, several controversies exist concerning its application to pleural empyema complicating pulmonary resections less than pneumonectomy. Between January 1993 and December 2003, 19 patients (16 male and 3 female) were treated for a pleural empyema complicating partial lung resection. The median age was 62 years (range, 17 to 79). Five patients (26%) had a bronchopleural fistula. In 2 patients (10%), successful control of the infection was achieved with the OWT. In 10 patients (56%), the OWT was closed by obliteration of pleural cavity with antibiotic solution (2 patients) or intrathoracic muscle transposition (8 patients). OWT closure was successfully performed in all of 5 patients with postoperative pleural empyema due to bronchopleural fistula. Prolonged chest drainage was not successful in any patient with late onset postoperative pleural empyema. Univariate analysis revealed that previous left pulmonary resections (p < 0.05) and timing of OWT (p < 0.001) were significant predictors of empyema healing after pulmonary resections smaller than pneumonectomy. Immediate OWT is a significant predictor of empyema healing after partial lung resection. Smaller pleural cavities appeared to increase the likelihood of healing. Prolonged chest tube drainage failed to control the infection in late onset of postoperative pleural empyema due to entrapped lung.

A Small Alveolar Adenoma Resected by Thoracoscopic Surgery

Alveolar adenoma (AA) is a rare lung benign tumor originated from type II pneumocytes. It presents as a well-defined nodule in clinical images, but is difficult to differentiate from early-stage lung cancer. We treated a 58-year-old woman with a small-sized AA measuring 8 x 6 mm in the upper lobe of the left lung by performing a thoracoscopic resection. The AA does not cause any symptoms and it is often incidentally detected as an abnormal shadow. There have been no reported cases of recurrence after a resection of AA, but a subsequent increase in such cases is expected, and we believe that it is necessary to understand the characteristics of this typical benign lung tumor.

Gastric Metastasis of Breast Cancer in a Male Patient: Report of a Case

A 65-year-old male patient presented with epigastralgia. At 57 years of age, the patient was diagnosed as cancer of the right breast (T1cN0M0) and underwent a mastectomy and axillary dissection. ER and PgR were positive, and HER2 was 2+. At six years after surgery, multiple metastatic lung tumors were found to have developed, and the patient underwent a partial resection of the left lung. Supraclavicular and mediastinal lymph nodes and pleural metastasis also developed postoperatively and were treated with chemotherapy. The patient developed epigastralgia at 30 months after the lung surgery, and underwent upper gastrointestinal endoscopy. An elevated lesion with a bridging fold was detected in the middle body of the stomach, and the results of a biopsy showed adenocarcinoma. The immunohistochemical staining results were positive for cytokeratin (CK) 7 and negative for CK20, and the patient was diagnosed as breast cancer metastasis to the stomach. Although breast cancer metastasis to the stomach has been detected in a small percentage of cases based on autopsy findings, it is extremely rare that a diagnosis of this disease is made in the clinical setting. A case of breast cancer metastasis to the stomach in a male patient is even rarer. A search of the Japan Centra Revuo Medicina database revealed only one such case among previous reports in Japan. In conclusion, it is necessary to address the possibility of breast cancer metastasis to the stomach when searching for a gastric tumor in a patient with a past history of breast cancer.

Anaplastic large cell lymphoma with cardiac metastasis. A case report

We present a case of an anaplastic large cell lymphoma (ALCL) in a 61 years old patient with multiple metastases including cardiac metastasis (left posterior ventricular wall). Anaplastic large cell lymphoma, ALCL is a rare condition in adult and cardiac metastasis are extremely rare. Most probably the metastatic spread was a hematogenous invasion via the coronary arteries. Initially a pulmonary small cell carcinoma was diagnosed and the patient underwent a lung partial resection. However, H&E histopathology demonstrated a specific pattern for the tumoral cells (“hallmark” cells); further immune histochemistry (RTU Peroxidase Detection System for Novocastra RTU Primary Antibodies, RE7100-CE), proved to be positive for CD 30, identifying an anaplastic large cell lymphoma, ALCL. Other markers were searched on using IHC techniques in order to confirm the affiliation to the lymphoma family (CD30, CD 3, CD 20 positive) and to exclude the affiliation to the pulmonary carcinoma and neuroendocrine tumors (Pan CK AE1-AE3, TTF1, CK 7, CD56 negative) or pluripotential hemopoietic stem cells or vascular-associated tissue including monocytes/macrophages (CD 34, CD 68 negative).

Toracoscopia aplicada à ressecção de fragmento pulmonar com o auxílio de sutura mecânica em eqüinos

Este trabalho visou à ressecção de fragmento dorsocaudal do lobo pulmonar caudal esquerdo com o auxílio de sutura mecânica por via toracoscópica. Foram utilizados 10 eqüinos clinicamente sadios, os quais foram sedados e mantidos em estação. O procedimento foi realizado no hemitórax esquerdo, por três acessos previamente programados: o primeiro acesso foi no 12º espaço intercostal (EIC), o segundo no 14º, 15º ou 16º EIC e o terceiro no 14º ou 15º EIC, conforme a necessidade de posicionamento dos instrumentos. Em todos os animais foi possível controlar o pneumotórax, sendo observada evolução clínica satisfatória durante o período pós-operatório, exceto em um animal. Os resultados obtidos indicam que, por meio da videotoracoscopia, pode-se realizar ressecção pulmonar parcial com uso de sutura mecânica em eqüinos e seu emprego na rotina hospitalar poderá contribuir para melhor compreensão e controle de enfermidades sediadas na cavidade torácica.

Mucosa-associated lymphoid tissue lymphoma involving lung and conjunctiva

A 68-year-old man was found to have tumors of the left lung and left conjunctiva. Thoracoscopic partial lung resection was performed. Histological examination revealed diffuse proliferations of centrocyte-like cells with lymphoepithelial lesions, and a diagnosis of mucosa-associated lymphoid tissue (MALT) lymphoma was made. Immunohistochemical study and flow cytometric analysis were also compatible with MALT lymphoma. Conjunctival tumor biopsy was performed and the diagnosis was confirmed. The postoperative course of the patient was uneventful, and he is currently being followed without further treatment.

Magnetic Navigation System for Thoracoscopic Surgery: a Partial Lung Resection with Transbronchial Marking

In order to detect and track a small magnet embedded in the vicinity of a target tumor during surgery, we have developed a magnetic navigation system based on three-dimensional measurements with micro-fluxgate magnetic sensors. In this paper, we present an image overlay method for superimposing the embedded magnetic marker through a bronchoscope. To evaluate the performance of the proposed system and its applicability in clinical use, we set up an in vivo experiment, in which surgeons used this system to perform thoracoscopic surgery on a pig with transbronchial marking and oblique-viewing, and we succeeded in a partial resection of the pig lung including the target area. Next, we tried a wedge resection for a lung tumor in a clinical case. We successfully performed the partial resection of the lung including the target area, which corresponded to the tumor lesion, under the guidance of the magnetic navigation system.

Lung resection in cystic fibrosis: A survival analysis

Lung resection may be considered for cystic fibrosis (CF) patients showing localized severe chronic atelectasis and/or bronchiectasis. Nonetheless, literature on survival after surgery is scarce. This study was carried out to assess survival time after partial lung resection. Twenty-one CF patients were operated from 1988 to 2003 and were followed until November 30th, 2004. Survival analysis was performed through Kaplan-Meier method. Mean age at resection was 8.09 years (SD 4.40 years) and two-thirds were females. Z-scores for height, weight, and body mass index as well as FEV1 values showed no statistical significance when comparing values obtained from 2 years before to 2 years after resection. Eleven years after resection, survival probability was 93.8%. Our results suggest that lobectomy or segmentectomy are safe procedures and should be considered in carefully selected patients with unilateral severe symptomatic localized and chronic persistent atelectasis and/or bronchiectasis refractory to conservative management.

Clinical application of infrared thoracoscopy to detect bullous or emphysematous lesions of the lung

We have previously reported that infrared thoracoscopy was useful in detecting emphysematous lesions in a canine model of lung emphysema. We applied infrared thoracoscopy to determine the feasibility and efficacy of planning bullectomy for patients with spontaneous pneumothorax. A total of 8 patients with spontaneous pneumothorax were included in the study. No procedure-related complications were observed. Infrared thoracoscopy with a single injection of indocyanine green (3.0 mg/kg) was used to detect bullous lesions of the lung during surgical intervention. Partial lung resections of the bullous lesions were performed after image analysis based on color density data obtained by means of infrared thoracoscopy. Bullous or emphysematous lesions of the lung were demonstrated in white, whereas normal lung tissue was imaged in blue, under infrared thoracoscopy. We were able to detect small bullous lesions with infrared thoracoscopy because of its clearer visualization compared with thoracoscopy. Quantitative color-density analysis revealed a marked decrease of indocyanine green intensity, which reflected decreased blood flow of bullous lesions. All resected specimens were confirmed as bullous lesions based on microscopic examinations. Infrared thoracoscopy-guided lung resection is a safe and useful procedure in detecting small bullous lesions.

P3-057: Magnetic navigation system for thoracoscopic surgery of the lung partial resection with transbronchial marking

P3-057: Magnetic navigation system for thoracoscopic surgery of the lung partial resection with transbronchial marking

Sharp rib fragment threatening to lacerate the aorta in a patient with flail chest

A 50-year-old man who was the victim of an accident during work was taken to the hospital. His chest radiograph and computed tomography (CT) scan showed pulmonary contusion, multiple rib fractures (left 5th to 1lth ribs), hemopneumothorax, and splenic rupture. On the fourth posttrauma day, CT showed bone particles of the ninth rib migrating to the thoracic aorta. These bone particles were threatening to penetrate the thoracic aorta. He underwent operation to repair the flail chest by approximating the left ribs and partial lung resection. After the operation the flail chest improved, enabling extubation the first day after the operation. He was mobile and was discharged on the 17th postoperative day. A literature review revealed cases of sudden death when such rib fragments lacerated the aorta. We therefore propose an early operation for patients who have multiple bone fractures in the left chest.

Thoracic sympathetic block reduces respiratory system compliance.

Thoracic epidural anesthesia (TEA) following thoracic surgery presents known analgesic and respiratory benefits. However, intraoperative thoracic sympathetic block may trigger airway hyperreactivity. This study weighed up these beneficial and undesirable effects on intraoperative respiratory mechanics. Randomized, double-blind clinical study at a tertiary public hospital. Nineteen patients scheduled for partial lung resection were distributed using a random number table into groups receiving active TEA (15 ml 0.5% bupivacaine, n = 9) or placebo (15 ml 0.9% saline, n = 10) solutions that also contained 1:200,000 epinephrine and 2 mg morphine. Under general anesthesia, flows and airway and esophageal pressures were recorded. Pressure-volume curves, lower inflection points (LIP), resistance and compliance at 10 ml/kg tidal volume were established for respiratory system, chest wall and lungs. Students t test was performed, including confidence intervals (CI). Bupivacaine rose 5 +/- 1 dermatomes upwards and 6 +/- 1 downwards. LIP was higher in the bupivacaine group (6.2 +/- 2.3 versus 3.6 +/- 0.6 cmH2O, p = 0.016, CI = -3.4 to -1.8). Respiratory system and lung compliance were higher in the placebo group (respectively 73.3 +/- 10.6 versus 51.9 +/- 15.5, p = 0.003, CI = 19.1 to 23.7; 127.2 +/- 31.7 versus 70.2 +/- 23.1 ml/cmH2O, p < 0.001, CI = 61 to 53). Resistance and chest wall compliance showed no difference. TEA decreased respiratory system compliance by reducing its lung component. Resistance was unaffected. Under TEA, positive end-expiratory pressure and recruitment maneuvers are advisable.

Early Pulmonary Resection for Mycobacterium Avium Complex Lung Disease Treated With Macrolides and Quinolones

The purpose of this study was to examine the postoperative outcomes of patients with Mycobacterium avium complex (MAC) lung lesions persisting despite treatment with multiple antibiotics. Patients with localized pulmonary lesions persisting despite extensive state-of-the art antimicrobial chemotherapy became candidates for surgical resection. Twenty-two patients who were expected to retain sufficient postoperative pulmonary function were included in this study. These patients received chemotherapy for 2 to 37 months (mean, 17). Surgical procedures were lobectomy (n = 15), segmentectomy (n = 4), and partial lung resection (n = 6). Three patients underwent bilateral resections. Mycobacterium avium complex causing bronchiectasis or cavitary lesions was detected preoperatively in all 22 patients. There was no major operative morbidity or mortality. Postoperative chemotherapy was continued for 6 to 35 months. All patients were alive and well at follow-ups ranging from 6 to 164 months (median, 46). Both vital capacity and forced expiratory volume in 1 second after surgery were maintained at 89% and 84% of the preoperative values, respectively. Mycobacterium avium complex disappeared from sputum after surgery in all patients. In 1 patient, 4 months after resection of a cavitary lesion, MAC-positive sputum presumed to be from the contralateral lung lesion became negative during continuation of chemotherapy. The long-term outcomes of patients operated on for MAC resistant to antimicrobial chemotherapy were excellent. For such patients, we recommend surgery before the disease becomes exceedingly advanced and nonresectable. Additionally, in extensive disease, the excision of large cavitary bacterial foci may assist the medical management of contralateral lesions.

Lung regeneration: Implantation of fetal rat lung fragments into adult rat lung parenchyma

The capability of regeneration of lung tissues in adults is limited after chronic destruction. Bone marrow-derived stem cells, retinoic acid, growth factors, and other approaches have been attempted to promote or facilitate this process. We hypothesized that fetal lung tissues, with great potential for growth and differentiation, could be used for lung regeneration. Day 17 fetal lung tissue fragments at the pseudoglandular stage of lung development from Lewis rats were implanted into adult Lewis rat lungs. For group 1, fetal lung fragments were injected into the adult left lung parenchyma; for group 2, fetal fragments were injected with the left lung partially resected; for group 3, adult fragments were injected; and for groups 4 and 5, fetal fragments were implanted into the omentum and subcutaneous tissue, respectively. The grafts implanted into pulmonary parenchyma were differentiated with opening of the alveolar space after 4 weeks and were advanced further with morphologic features similar to those of neonatal lungs after 8 and 12 weeks. The implants were connected with pulmonary circulation determined by means of perfusion with India ink. These changes appeared to be further enhanced in animals with partial lung resection that might have facilitated the maturation of implanted fetal lung tissues through mechanical factors, soluble factors, or both. Fetal lung tissues did not mature when implanted into the omentum or subcutaneous tissue. Adult lung fragments did not expand after being reimplanted back into the same animal. Fetal lung tissue might be an option for further investigation into lung regeneration.

新たに作成した肺部分切除用鉗子の有用性に関する検討 : 5症例に対する使用経験

新たに作成した肺部分切除用鉗子の有用性に関する検討 : 5症例に対する使用経験

Coexistence of metastatic lung cancer and pulmonary tuberculosis diagnosed in the same cavity

A 79-year-old woman who had a past history of chronic renal failure 10 years earlier, tongue cancer (T2N2M0) 3 years earlier, and tuberculosis of the cervical lymph nodes 6 months earlier was suddenly admitted with the complaint of right chest pain on April 6, 2004. Right pneumothorax and mild pleural effusion were observed on a chest radiograph. There was no improvement in the patients collapsed lung despite the insertion of a chest drainage tube into the pleural cavity. Three thin-walled cavitary lesions were noted in the right lobe of segment 1 on computed tomography, and the cause of her pneumothorax was thought to be air leakage from the largest cavitary lesion adjacent to the visceral pleura. Partial resection of the right lung by video-assisted thoracoscopic surgery (VATS) was performed at the Department of Thoracic Surgery. Subsequently, it was determined that metastatic squamous cell carcinoma of the lung, corresponding to her tongue cancer, had invaded the visceral pleura adjacent to the largest cavitary lesion. Simultaneously, an epitheloid granuloma with caseating necrosis was observed adjacent to a partially thickened portion of this cavitary lesion. The epitheloid granuloma was found to be acid-fast bacilli-positive and a diagnosis of Mycobacterium tuberculosis pulmonary tuberculosis was made. We report a rare case of the coexistence of metastatic lung cancer originating from tongue cancer and active pulmonary tuberculosis diagnosed in the same large cavitary lesion.

Chronic pulmonary scedosporiosis simulating aspergillosis

Scedosporium apiospermum, a ubiquitously distributed saprophyte, is emerging as an important pathogen in immunocompromised patients. We describe a 72-year-old patient with chronic S. apiospermum infection of the lung simulating aspergilloma. His medical history was unremarkable except that he had undergone partial lung resection as a treatment for pulmonary tuberculosis several decades previously. He had no underlying immunosuppressive conditions. This patient illustrates that pulmonary scedosporiosis is not confined to immunocompromised patients and that the clinical presentation may be indistinguishable from that of aspergilloma.

Annual Periodic Increases in Serum Carcinoembryonic Antigen Concurrent with Ground-Glass Opacity in the Lung: Report of a Case

A 63-year-old woman underwent a video-assisted thoracoscopic lobectomy for cancer of the right lung in 1999. The following year, a lesion with ground-glass opacity was found in the left lung, and pathological examination after a partial lung resection revealed atypical adenomatous hyperplasia with expression of carcinoembryonic antigen (CEA). During postoperative screening tests for tumor recurrence, there were periodic increases in the serum CEA level by twofold above the normal levels in 2002 and 2003. Clinical evaluations, including laboratory tests, radiographic imaging, and endoscopy examinations, showed no evidence of a CEA-producing tumor, except for a new ground-glass opacity in the left lung. To our knowledge, this is the first report of periodic increases in serum CEA levels in a patient with ground-glass opacity in the lung, not reflecting recurrence of the lung tumor.

Magnetic navigation system for thoracoscopic surgery of the pig lung partial resection with transbronchial marking

In order to detect and track the small magnet embedded in the vicinity of a target tumor during surgical operation, a magnetic navigation system based on the three-dimensional measurement with micro-fluxgate magnetic sensors was developed. In this paper, we present an image overlay method for superimposing the magnet marker embedded through bronchoscope. To evaluate the performance of the proposed system and its applicability in clinical use, we set up an in vivo experiment, in which the surgeons used the system to perform a thoracoscopic surgery on a pig with transbronchial marking with oblique-viewing. As a result, the surgeons could operate the partial resection of the target area, which corresponded to the tumor lesions, of the pig lung easily and safely under the guidance of the magnetic navigation system.

Release of Glutaraldehyde From an Albumin-Glutaraldehyde Tissue Adhesive Causes Significant In Vitro and In Vivo Toxicity

A two-component sealant composed of bovine serum albumin and glutaraldehyde (BioGlue) is used to treat aortic dissections. Although glutaraldehyde guarantees strong adherence to tissues and synthetic materials, its toxic potential should be considered. The aim of this study was to determine the amount of glutaraldehyde released from BioGlue, its cytotoxic effects on cultured cells, and the local reaction of lung, liver, and aortic tissues to BioGlue. BioGlue was prepared according to the product insert, allowed to polymerize, and then overlaid with saline solution. The supernatant was analyzed for its content of glutaraldehyde. The cytotoxic effect of BioGlue was evaluated by adding the supernatants to either cultured human embryo fibroblasts (MRC5) or mouse myoblasts (C2C12). In vivo toxicity was assessed on three different tissues by applying BioGlue onto a partial lung resection, a liver abrasion, or an intact abdominal aorta in rabbits. Tissue samples were histologically evaluated 2 and 7 days after application. Saline supernatants from polymerized BioGlue contained 100 to 200 mug/mL glutaraldehyde and were cytotoxic to both cell lines tested. Application of BioGlue to lung and liver tissue evoked serious adverse effects consisting of high-grade inflammation, edema, and toxic necrosis. Intact aortic tissue showed only low-grade or medium-grade inflammation. Polymerized BioGlue releases amounts of glutaraldehyde that are capable of inducing cytotoxic effects both in vitro and in vivo. Use of BioGlue should be restricted to the aortic dissection procedure, as other tissues are sensitive to the amounts of glutaraldehyde released from the glue.