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

Photodynamic therapy (PDT) utilizes a tumor-specific photosensitizer with low-power laser irradiation and this treatment has been established for centrally located lung cancers. However, its application to peripheral type lung cancers remains investigational. Recently, there has been interest in minimally invasive ablative therapies are needed for peripheral type lung cancer and several bronchoscopic ablative modalities are currently under investigation. In this study, a novel laser probe was developed and a multicenter randomized clinical trial was conducted to assess the safety and efficacy of PDT for peripheral lung cancer, and to establish a novel bronchoscopic treatment. Patients with non-small cell lung cancer diagnosed by transbronchial lung biopsy with a tumor diameter of 25 mm or less and ineligible for surgery or radiotherapy were enrolled. A randomized controlled trial was conducted with a 2:1 ratio between the PDT group and the best supportive care (BSC) group. The primary endpoint was progression-free survival (PFS), and the secondary endpoint was overall survival (OS). For the BSC group, salvage PDT (sPDT) was permitted for patients with a PD diagnosis and a tumor diameter of 30 mm or less. Patients were enrolled from May 2020 to May 2023 at six hospitals, with a total of 54 cases included, including 35 cases in the PDT group and 19 cases in the BSC group. Among the cases in the BSC group, sPDT was performed in 14 cases. The median PFS was 12.7 months [95% confidence interval (CI): 6.7, 30.0] in the PDT group, and the median PFS was 4.1 months (95% CI: 2.9, 7.4) in the BSC group. Kaplan-Meier survival analysis (log-rank test, p=0.0172) demonstrated a significant prolongation of the PFS in the PDT group. The incidence of serious adverse events was 5.9% (two patients) in the PDT group and 0% in the sPDT group. The findings of this study indicate that PDT for peripheral lung cancer led to a significantly prolongation of PFS and was safe to perform. PDT demonstrated efficacy in preserving lung function, inhibiting lung cancer progression, and maintaining a good quality of life.

A woman in her 30s with a left posterior mediastinal tumor incidentally found on a chest computed tomography (CT) was referred to our hospital. Chest CT revealed a dumbbell-shaped tumor of 37 mm in diameter located on the paravertebral region at the left Th9/10 level. The tumor extended into the Th9 intervertebral foramen, but did not extend into the spinal canal. Three dimensional (3D)-CT showed the artery of Adamkiewicz (AKA) with a hair-pin turn from the 11th left intercostal artery. We performed surgical treatment. First, the nerve root was dissected by the posterior approach. Next, the tumor was resected by thoracoscopic surgery. The postoperative pathological diagnosis was neurinoma. In surgical resection of posterior mediastinal tumors (especially on the left side) located between the eighth thoracic vertebra and the first lumbar vertebra, it is considered important to identify AKA preoperatively in order to prevent postoperative paraplegia.

Mediastinoscopic esophagectomy (ME) for esophageal cancer, first reported by Tangoku et al. in 2004, has evolved into a standardized procedure incorporating radical lymphadenectomy. The surgery is performed using a mediastinoscope from the neck and a laparoscope from the abdomen, creating a connected operative field within the mediastinum. ME avoids thoracotomy and one-lung ventilation, preserving respiratory muscles and significantly reducing postoperative pneumonia, while maintaining pulmonary function and quality of life. Meta-analyses have shown that although recurrent laryngeal nerve palsy is relatively common, ME results in shorter operative time, less blood loss, lower incidence of pneumonia, and a reduced overall complication rate compared to conventional approaches. Its greatest advantage lies in expanding surgical indications to patients who were previously considered inoperable due to thoracic adhesions, poor pulmonary function (e.g., chronic obstructive pulmonary disease (COPD)), or prior thoracic surgery. These patients often cannot tolerate radiation either, making ME particularly valuable. As Japan's population continues to age, the need for ME is expected to grow. Although ME was covered by national insurance in 2018, evidence from Japan remains limited. The 2022 esophageal cancer guidelines refrain from recommending ME due to insufficient data. However, recent retrospective studies using propensity score matching have shown significantly better overall and disease-free survival compared to thoracotomy, and prospective multicenter trials are underway.

A 74-year-old woman was diagnosed with obstructive hypertrophic cardiomyopathy and symptoms of heart failure. Transthoracic echocardiography and other imaging examinations revealed an apical-basal muscle bundle caused by a left ventricular outflow tract(LVOT) obstruction. The peak velocity was 6.1 m/s, recorded during the Valsalva maneuver, and mitral regurgitation progressed from trivial to moderate. The course of operative treatment consisted of surgical intervention in the mitral valve. The LVOT revealed an apical-basal muscle bundle, approximately 6 mm in diameter;however, this was excluded. Extended septal myectomy and intraoperative transesophageal echocardiography were performed, the latter to verify the systolic anterior motion of the mitral valve;however, mitral regurgitation was not detected. The post-operative peak velocity improved to 2.5 m/s. In conclusion, surgical treatment of obstructive hypertrophic cardiomyopathy and LVOT obstruction associated with an apical-basal muscle bundle was performed with accurate diagnosis, thus avoiding valvular surgery.

The patient is a 73-year-old woman who was referred to our department for diagnostic surgery. A part-solid ground-glass nodule, suspected to be lung cancer, was identified in the right S6 on a preoperative chest contrast computed tomography (CT). Additionally, a continuous bronchial artery was observed at the root of A6. Based on the CT findings, we diagnosed a bronchial-pulmonary artery fistula (BPAF) and an associated pulmonary artery aneurysm. The patient exhibited no subjective symptoms, such as blood-streaked sputum or hemoptysis. She subsequently underwent a right S6 segmentectomy. Intraoperative examination of the pulmonary artery revealed a continuous bronchial artery dorsal to A6, as anticipated. Intravenous indocyanine green (ICG) administration after root ligation of A6 showed that ICG flowed into A6 and peripherally to S6 beyond the ligated point via the bronchial artery, confirming the diagnosis of BPAF.

We report a successful case of minimally invasive cardiac surgery for partial anomalous pulmonary venous connection and sinus venosus atrial septal defect. A 45-year-old man had a severely enlarged right heart due to partial anomalous pulmonary venous connection and sinus venosus atrial septal defect, but no evidence of severe pulmonary hypertension was observed. Right third intercostal approach was used to incise the right atrium and the superior vena cava at the level of the partial anomalous pulmonary venous connection confluence so that the partial anomalous pulmonary venous connection orifice and the sinus venous atrial septal defect were well observed under endoscopic assistance. Intracardiac repair was performed by suturing a Gore-Tex patch with a continuous suture of 5-0 polypropylene thread through the two incision lines in the heart. Postoperative examination revealed no residual shunt or stenosis of the pulmonary vein or the superior vena cava, and the patient was discharged without complications.

Lung segmentectomy for small peripheral lung cancers has been increasingly performed in recent years. A critical step in this procedure is the intersegmental plane dissection, which, if not performed properly, may lead to complications such as prolonged air leakage. Traditionally, electrocautery and staplers have been commonly used for this purpose. In this report, we describe our experience using a domestically developed microwave surgical instrument. This device utilizes 2,450 MHz microwave energy to vibrate water molecules within tissue, creating a uniform coagulation layer while keeping tissue temperatures below 100 ℃. This allows for effective sealing of the lung parenchyma. Additionally, its scissor-like shape enables intuitive and precise handling during dissection. Our initial experience demonstrated minimal intraoperative bleeding and a low rate of postoperative complications. These results suggest that the microwave surgical device may offer a safe and effective alternative for lung parenchymal dissection in segmentectomy. Its ability to create a consistent seal without excessive thermal damage may help improve surgical outcomes and reduce postoperative morbidity. This technique could be particularly useful in cases requiring precise anatomical dissection, supporting its broader adoption in thoracic surgery.

We report a case of a 49-year-old man with distal stent-graft-induced new entry (d-SINE) three months after first thoracic endovascular aortic repair( TEVAR) for acute complicated type B aortic dissection (acTBAD). The d-SINE led to acTBAD recurrence of acTBAD, resulting in malperfusion of the lower limbs and kidneys. The d-SINE was observed in the aorta at the Th8 level, and there was an obvious re-entry in the left common iliac artery( CIA). Additional TEVAR was performed using a modified extended provisional extension to induce complete attachment (e-PETTICOAT). Without balloon dilation, a straight stent graft (SG) was inserted into the aorta at the level of superior to the celiac trunk, then a bifurcated SG was placed from below the renal artery( RA) to the CIA, and finally a bare stent was inserted between them. The d-SINE and retry tears of the acTBAD were closed simultaneously. Despite extensive stent graft placement, we were able to improve the malperfusion of the lower limbs and kidneys and prevent aortic rupture without causing neurological complications. No SINE occurred, and good aortic remodeling was achieved from the left subclavian artery( LCA) to the CIA 14 months after the additional TEVAR.

A 65-years-old female was admitted to our hospital for treatment of fever and chest pain. Contrast-enhanced computed tomography (CT) revealed an anterior mediastinal tumor with a thickened wall, and right pleural effusion. Ten days after antibiotic therapy, the fever, chest pain and pleural effusion disappeared. Thymectomy was performed to confirm the diagnosis. Histopathologic diagnosis was type B2 thymoma with extensive necrotic area, Masaoka's stageⅠ. No recurrence has been observed for approximately two years since the surgery. Thymomas have a variety of pathological features such as cystic and hemorrhagic changes and necrosis. However, thymomas with extensive necrosis are very rare. We presented this case with a review of the literature.

Cardiac herniation is a rare complication after pulmonary surgery. A 59-year-old woman underwent right-sided pneumonectomy for right pulmonary squamous cell carcinoma, pulmonary vein was ligated intrapericardialy and the pericardial defect, which mesasured about 2 cm was not repaired. After four months, the patient complained of bilateral lower leg edema and dyspnea on effort. Computed tomography (CT) showed the right atrial herniation into the right-sided thoracic cavity. We diagnosed with symptomatic cardiac herniation and performed opration with small thoracotomy. At operation it was found that the right atrium herniated into the right-sided thoracic cavity. There were no adhesions between the pericardium and the right atrium. We placed the right atrium back within the pericardium and repaired using a bovine pericardial patch. The postoperative course was uneventful. Bilateral lower leg edema and cardiac herniation disappeared. Cardiac herniation did not recur over four years postoperatively.