Kyobu geka. The Japanese journal of thoracic surgery最新文献

Background: We introduced the uniportal robotic assisted thoracic surgery (URATS) using da Vinci Xi in 2023 after notification to and approval by the Highly Difficult and New Medical Technology Review Division of the Osaka University Hospital. In our department, URATS is indicated for c-stage 1 lung cancer, metastatic lung tumors, and benign diseases.

Methods: The cross-shaped center guide point is aligned with the dorsal surface of the window. The most dorsal arm is not used, and the camera is placed on the dorsal side. The assistant checks which arm is interfering and adjusts the position and height of the port to find a point where there is no interference. It is also important to select a field of view that allows safe manipulation of the target structure without interference, rather than sticking to one field of view.

Discussion: One of the advantages of the URATS is that it allows for a close view. While this allows for highly accurate surgery, it also has disadvantages in terms of cost and learning curve. We plan to continue to accumulate and validate cases, as this may be a beneficial treatment option for patients.

With the aging population, the prevalence of aortic stenosis (AS) is increasing, and transcatheter aortic valve implantation (TAVI) has become a promising treatment, particularly for high-risk patients. Over the past decade, TAVI technology has advanced rapidly, and three major devices-SAPIEN (balloon-expandable), Evolut (self-expanding), and Navitor (self-expanding)-are now widely used in Japan. Each device offers unique structural and procedural characteristics: SAPIEN provides precise positioning and strong anti-paravalvular leak features; Evolut offers excellent hemodynamics, especially in small annuli; and Navitor features a flexible delivery system and enhanced sealing via NaviSeal. Long-term data show favorable outcomes for all devices, though each has distinct advantages and limitations. Recent concerns include the management of younger patients and the rise in TAVI explant procedures. Thus, selecting the optimal device based on patient anatomy, risk profile, and future reintervention potential is increasingly emphasized. This review summarizes the key features and clinical outcomes of these devices and discusses future directions toward personalized treatment strategies, including lifetime management approaches. As TAVI expands to lower-risk and younger populations, balancing durability, procedural safety, and reintervention strategies will be essential to ensuring long-term clinical success.

The introduction of the da Vinci SP system has led to the classification of surgical robotic platforms into multiple-port and single-port systems. Esophagectomy for esophageal cancer can now be performed through various approaches, including transthoracic, transcervical, transhiatal, and subcostal routes. Future studies are warranted to determine which robotic system is most suitable for each approach and provides optimal short- and long-term outcomes.

Drug-resistant severe heart failure significantly impairs cardiac pump function, affecting both prognosis and quality of life (QOL). When conventional treatments are ineffective, a ventricular assist device (VAD) can support heart function. Heart transplantation remains the ultimate treatment, but donor shortages and eligibility constraints limit access. The left ventricular assist device (LVAD) is a crucial option, serving as a bridge to transplantation (BTT) or a permanent destination therapy (DT) for ineligible patients. In Japan, DT was covered by insurance in 2021, expanding from 7 to 19 facilities by 2023. Key differences between BTT and DT include the removal of the age limit (65 years) and reduced caregiver requirements. LVAD technology has advanced, with miniaturization improving implantation feasibility and reducing surgical burden. Pump designs have evolved from pulsatile to continuous-flow types, with axial and centrifugal models enhancing efficiency. Innovations in biocompatibility and wireless power transmission aim to reduce complications and improve long-term outcomes. BiVACOR, a fully implantable total artificial heart using magnetic levitation, was first clinically tested in 2024. While currently limited to temporary use before transplantation, further advancements may lead to broader applications, enhancing patient survival and QOL.

Currently, board certification for cardiovascular surgeons in Japan mandates a minimum of 30 hours of off the job training (OJT). However, starting in June 2024, training hours will be doubled when conducted under the auspices of the Japanese Societies of Thoracic, Cardiovascular, and Vascular Surgery, and increased by 1.5 times when using animal tissue, simulators, or three dimensional (3D) printing models. The growing adoption of minimally invasive techniques has led to a decline in traditional median sternotomy procedures, thereby reducing direct operative experience for young surgeons and underscoring the need for innovative training methods. Simulation tools in cardiovascular surgery span a wide range in both fidelity-the extent to which a model replicates real anatomical conditions-and cost. Options vary from low-cost, low-fidelity homemade models using everyday materials to high-fidelity systems employing porcine hearts or cadaveric tissues. Recent innovations include smartphone-based applications, such as the e-Suture app, which provides objective evaluations of needle handling, and online training platforms that have enabled remote coronary artery anastomosis training during the coronavirus disease (COVID)-19 pandemic. Moreover, high-fidelity simulators using 3D printing technology and robotic surgery training devices have broadened the scope of available educational resources. Ultimately, it is most important for trainees to be aware of the need to transfer their skills to clinical practice when undergoing training.

A 56-year-old woman with a congenital bicuspid aortic valve presented with a cough. She was diagnosed with adult congenital coarctation of the aorta on computed tomography(CT) and referred to our institution. The blood pressure gradient between the upper and lower extremities was approximately 70 mmHg. She also had mild renal impairment. She underwent left subclavian artery to descending aorta bypass through a 5th left thoracotomy with partial extracorporeal circulation. The operation was successful and the postoperative course was uneventful. The pressure gradient between the upper and lower extremities eventually decreased to 5 mmHg. The left subclavian artery to descending aorta bypass is an effective operation for this disease.

A 52-year-old woman was referred to our hospital with a chief complaint of difficulty in swallowing and coughing while eating. Enhanced computed tomography (CT) revealed a Kommerell diverticulum with right aortic arch and aberrant left subclavian artery. The diverticulum compressed the esophagus and trachea. We avoided total aortic arch replacement because there were risks of circulatory arrest, selective cerebral perfusion and neurological complication including injury to recurrent laryngeal nerve. Therefore, we scheduled two-stage repair of the diverticulum. First, we performed axillo-axillary artery bypass and left subclavian artery coil embolization. After 7 days, descending aorta replacement including a diverticulum with right anterior lateral 3rd intercostal thoracotomy and lower body partial extracorporeal circulation was performed. The postoperative course was uneventful and she was discharged 20 days after the initial surgery.

Neurological complications during thoracic and thoracoabdominal aortic surgery remain significant issues affecting both postoperative quality of life and long-term survival. Inadequate cerebral and spinal cord perfusion, as well as embolic events, are major contributors to such outcomes. Near-infrared spectroscopy (NIRS)-based regional cerebral oxygen saturation (rSO2) monitoring allows continuous, non-invasive assessment of cerebral perfusion and has become a routine adjunct in high-risk procedures. Factors such as mean arterial pressure, arterial carbon dioxide tension (PaCO2), hemoglobin levels, and cardiac output all significantly influence rSO2 values. For spinal cord protection, motor evoked potential (MEP) monitoring provides a real-time assessment of the corticospinal tract integrity. Its utility is particularly prominent in thoracoabdominal aortic aneurysm repairs where spinal ischemia poses a risk of paraplegia. Prompt intraoperative responses-such as increasing blood pressure, cerebrospinal fluid drainage, or intercostal artery reconstruction-can be initiated based on MEP changes. At our institution, over 300 cases have been managed with MEP guidance, yielding favorable neurological outcomes. Integration of NIRS and MEP enables early detection of ischemia and timely interventions, thereby reducing neurological complications. Continued refinement and standardization of these modalities, in conjunction with other physiological and imaging assessments, are essential to further improve surgical outcomes.

Robotic bronchoscopy is an innovative bronchoscopic technique that combines advanced navigation systems with precise robotic control. This integration allows for highly accurate maneuvering and enhanced procedural safety, thereby contributing to further minimally invasive approaches in bronchoscopic diagnostics. In addition to diagnostic applications, its superior reach and stability suggest promising potential for future therapeutic interventions, such as bronchoscopic ablation. These developments indicate that a "one-stop shop" encompassing both diagnosis and treatment of lung cancer may soon become a reality. Although robotic bronchoscopy has not yet been introduced in Japan, its adoption is rapidly progressing in North America. Furthermore, other regions are also witnessing increased regulatory approvals and implementation of robotic-assisted bronchoscopic systems. As technological advancements continue and clinical evidence accumulates, the global dissemination of robotic bronchoscopy is expected to accelerate, potentially transforming the landscape of pulmonary medicine.

A 44-year-old female had a history of the treatment of pulmonary tuberculosis at the age of 17 and was diagnosed with the stenosis of the left main bronchus at the age of 18. Twenty-five years after the completion of pulmonary tuberculosis treatment, she suffered from severe dyspnea and wheeze. Her symptoms were due to endobronchial tuberculosis;the left main bronchus was stenotic and the left upper bronchus was completely obstructed, causing atelectasis of left upper lobe. Despite two years of medical treatment, her symptoms did not improve and she was referred to our hospital. She underwent bronchoscopic balloon dilatation twice, and her bronchial stenosis was alleviated. However, she still had a severe dyspnea due to bronchial malacia. We decided to perform a left upper sleeve lobectomy. Her symptoms were dramatically resolved after the surgical operation. Treatment of endobronchial tuberculosis remains challenging and there is no established treatment strategy. From the view of minimally invasive treatment, bronchoscopic intervention should be the treatment of choice. However, surgical treatment should be considered for the patients who did not improve with bronchoscopic intervention or who had re-stenosis after it.