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PURPOSE To investigate the accuracy of a segment-counting method in predicting lung function and volume after stapler-based thoracoscopic segmentectomy in comparison with lobectomy. METHODS Between 2014 and 2018, patients who underwent these procedures were retrospectively reviewed. Thoracic computed tomography and spirometry data before and 1 year after the surgery were assessed. We evaluated the differences between the predicted values using a segment-counting method and the actual postoperative values for lung function and volume in each group. Sub-analyses were also performed to assess the impact of the number of staples and resected segments in predicting patient outcomes. RESULTS We included 116 patients (segmentectomy, 69; lobectomy, 47). Actual postoperative lung function and volume values matched the predicted values in the stapler-based segmentectomy group, and significantly exceeded the predictions in the lobectomy group (P

Thoracoscopic resection of the anterior segment of the left upper lobe (S3) is technically challenging because of the intricate hilar structure and multiple intersegmental planes to be dissected. A single-direction approach for S3 segmentectomy is a technique in which surgeons dissect the hilum structures exclusively from the ventral side without dividing the interlobar fissure. Our consecutive case series and a representative surgical video demonstrated the feasibility of this approach in cases where the lingular artery arises from the first branch of the left pulmonary artery (mediastinal lingular artery).

There are few data available on the outcomes of postoperative recurrent thymic carcinoma (TC) and thymic neuroendocrine carcinoma (TNEC). The aim of this study is to evaluate the treatment and survival in patients with recurrent TC and TNEC after undergoing surgical resection. A retrospective chart review was performed using our multicenter database to identify patients with a postoperative recurrence of TC and TNEC from 1995 to 2018. The clinicopathological factors were reviewed and the survival outcomes were analyzed. Sixty patients were identified among 152 patients who underwent resection of TC and TNEC. The median follow-up period from the first recurrence was 14.8 months (range 0–144). The 5-year post-recurrence survival was 23% for the whole cohort. According to a univariable analysis, advanced stage [hazard ratio (HR) 2.81, 95% confidence interval (CI) 1.09–9.54], interval between primary surgery and recurrence (HR 0.97, 95% CI 0.95–0.99), any treatment for recurrence (HR: 0.27, 95% CI 0.13–0.58) and chemotherapy for recurrence (HR: 0.46, 95% CI 0.22–0.95) were significant factors related to post-recurrence survival. Chemotherapy rather than surgery appears to be the mainstay treatment for managing patients with postoperative recurrent TC and TNEC and it may also be considered in multidisciplinary management. Further studies with a larger sample size are required to confirm our findings.

The primary and secondary aims were to investigate the prevalence of incidental mediastinal masses on low-dose chest CT examinations during health check-ups, and to review the radiological characteristics of prevascular mediastinal masses, respectively. This retrospective study included 38,861 participants (mean age: 57.1 years; range: 21–99 years; men: 51.3%; never-smokers: 57.4%) who underwent low-dose chest CT examinations between January 2011 and December 2016. All images with incidental mediastinal masses were reviewed, and prevascular mediastinal masses were assessed for qualitative and quantitative imaging characteristics by two radiologists. Univariate and multivariate analyses were performed in clinical and CT features between some combinations of participants. Overall, 653 participants (1.68%, 653 of 38,861) had incidental mediastinal masses; 578 in prevascular mediastinum, including 93 intrathymic cysts and 24 thymic epithelial tumors. Presence of mediastinal mass was not significantly associated with sex (p = 0.089) and smoking history (p = 0.098) but with age (p

Postoperative changes in pulmonary function (PF) and morphology due to surgical chest wall damage by thoracotomy with rib resection are unclear. Therefore, we evaluated the effects of surgical damage on PF and morphology at > 6 months postoperatively by comparing different lung lobectomy approaches. A total of 140 patients who underwent lobectomy for lung diseases between January 2006 and March 2016 were analyzed. Patients who underwent PF tests and computed tomography (CT) scans preoperatively and postoperatively were divided into posterolateral thoracotomy with one rib resection (PT) group and video-assisted thoracoscopic surgery (VATS) group. A 1:1 propensity score-matched (PSM) analysis was used to balance clinically important confounders between the groups. Regarding morphology, lung volume was measured semi-automatically using image analysis software and reconstructed three-dimensional (3D) images. After PSM, 31 patients in each group were compared. Perioperative reduction ratios in forced vital capacity (FVC) (− 23% vs. − 13%; P = 0.006) and forced expiratory volume in 1 s (FEV1) (− 19% vs. − 12%; P = 0.02) were significantly larger for the PT group. No significant differences in lung volume values based on 3D CT volumetry (PT vs. VATS; total lung volume: − 7.9% vs. − 7.2%, P = 0.82; non-resected ipsilateral lung volume: + 36% vs. + 40%, P = 0.69; contralateral lung volume: + 9.3% vs. + 9.4%, P = 0.98) were found in either group. Among the patients underwent lobectomy, classic thoracotomy decreased PF by an additional FVC loss of 10% and FEV1 loss of 7% compared with VATS, without affecting residual lung volume.

Perioperative C-reactive protein (CRP) levels have become a contentious topic on the surgical outcome of lung cancer, but the influence of the procedure types has not been precisely investigated. From this viewpoint, we compared two types of thoracoscopic anatomical lung resection: segmentectomy and lobectomy. This was a retrospective study involving patients who underwent standardized anatomical lung resection at a single institute from 2014 to 2017; CRP levels were routinely measured on postoperative days 1, 3, and 5. Changes in the CRP levels from the preoperative period were calculated (ΔCRP), and factors associated with a higher ΔCRP value were analyzed. Among 186 patients included, 91 (48.9%) patients underwent stapler-based segmentectomy and 95 (51.1%) patients underwent lobectomy. The segmentectomy group showed significantly higher ΔCRP values on every measurement day than the lobectomy group, in spite of shorter operation time, smaller blood loss, shorter drainage periods, shorter dissection time, and limited lymph node dissection. The number of stapler cartridges for the lung parenchyma was significantly larger in the segmentectomy group. Regression analyses indicated that procedure type and smoking history were associated with a higher ΔCRP value, whereas no significant difference was indicated in the smoking history between the groups. In our cohort, stapler-based thoracoscopic segmentectomy was associated with an increase in acute inflammatory response despite favorable perioperative outcome compared to lobectomy. Local surgical stress and damage in the remaining segments might play a key role and warrants further investigation.

Objective Early-stage lung adenocarcinomas that are suitable for limited resection to preserve lung function are difficult to identify. Using a radiomics approach, we investigated the efficiency of voxel-based histogram analysis of 3-dimensional computed tomography images for detecting less-invasive lesions suitable for sublobar resection. Methods We retrospectively reviewed the medical records of 197 patients with pathological stage 0 or IA adenocarcinomas who underwent lung resection for primary lung cancer at our institution between January 2014 and June 2018. The lesions were categorized as either less invasive or invasive. We evaluated tumor volumes, solid volume percentages, mean computed tomography values, and variance, kurtosis, skewness, and entropy levels. We analyzed the relationships between these variables and pathologically less-invasive lesions and designed an optimal model for detecting less-invasive adenocarcinomas. Results Univariate analysis revealed seven variables that differed significantly between less invasive (n = 71) and invasive (n = 141) lesions. A multivariate analysis revealed odds ratios for tumor volumes (0.64; 95% confidence interval (CI), 0.46-0.89; P = .008), solid volume percentages (0.96; 95% CI, 0.93-0.99; P = .024), skewness (3.45; 95% CI, 1.38-8.65; P = .008), and entropy levels (0.21; 95% CI, 0.07-0.58; P = .003). The area under the receiver operating characteristic curve was 0.90 (95% CI, 0.85-0.94) for the optimal model containing these 4 variables, with 85% sensitivity and 79% specificity. Conclusions Voxel-based histogram analysis of 3-dimensional computed tomography images accurately detected early-stage lung adenocarcinomas suitable for sublobar resection.

Lung disease requiring surgical treatment has shifted from pulmonary tuberculosis that was prevalent in the 1940s during wartime to lung cancer in the last half century. The surgical approach for pulmonary tuberculosis was open chest surgery. Likewise for lung cancer, a thoracotomy approach had initially been used for a while. Thoracoscopic minimally invasive surgery became more widely used around 1990 and was shown to improve the patient's quality of life (QOL). Currently, thoracoscopic surgery and robotic surgery are the mainstream procedures for patients with lung cancer, and thoracotomy procedures have fallen out of favor. However, in some cases of unexpected bleeding from the pulmonary artery or tumor infiltration into the pulmonary artery, appropriate thoracotomy must be performed. In this volume, 4 representative methods of performing thoracotomy are described with some tips in Japanese.

Chest radiography showed a right posterior mass on the mediastinum of an 84-year-old woman. The mass had been growing gradually for four years. Surgical excision was performed, and a pathological examination found the mass to be consistent with primary synovial sarcoma (SS) of the mediastinum. To our knowledge, this is a rare case in which follow-up imaging was able to be performed over a period of four years. This disease is aggressive, and its early diagnosis is key to achieving a cure. It is important to consider primary SS in the differential diagnosis of a primary intra-thoracic tumor, even if the tumor grows slowly.

Flavin-containing monooxygenases (FMOs) are major mammalian non-cytochrome P450 oxidative enzymes. T helper 2 cell–activated allergic diseases produce excess levels of nitric oxide (NO) that modify the functions of proteins. However, it remains unclear whether allergy-induced NO affects the pharmacokinetics of drugs metabolized by FMOs. This study investigated alterations of hepatic microsomal FMO1 and FMO3 activities in type 1 allergic mice and further examined the interaction of FMO1 and FMO3 with allergy-induced NO. Imipramine (IMP; FMO1 substrate) N-oxidation activity was not altered in allergic mice with high serum NO and immunoglobulin E levels. At 7 days after primary sensitization (PS7) or secondary sensitization (SS7), benzydamine (BDZ; FMO1 and FMO3 substrate) N-oxygenation was significantly decreased to 70% of individual controls. The expression levels of FMO1 and FMO3 proteins were not significantly changed in the sensitized mice. Hepatic inducible NO synthase (iNOS) mRNA level increased 5-fold and 15-fold in PS7 and SS7 mice, respectively, and hepatic tumor necrosis factor-α levels were greatly enhanced. When a selective iNOS inhibitor was injected into allergic mice, serum NO levels and BDZ N-oxygenation activity returned to control levels. NO directly suppressed BDZ N-oxygenation, which was probably related to FMO3-dependent metabolism in comparison with IMP N-oxidation. In hepatic microsomes from PS7 and SS7 mice, the suppression of BDZ N-oxygenation was restored by ascorbate. Therefore, type 1 allergic mice had differentially suppressed FMO3-dependent BDZ N-oxygenation. The suppression of FMO3 metabolism related to reversible S-nitrosyl modifications of iNOS-derived NO. NO is expected to alter FMO3-metabolic capacity–limited drug pharmacokinetics in humans.

We report a case with suggestive antiprogrammed death-1 inhibitor-related pneumonitis in an endometrial cancer patient. This case presented with fever and cough after three dosages of nivolumab. Computed tomography initially showed centrilobular nodularities in a unilateral lung, which was compatible with aspiration pneumonia. However, diffuse ground-glass opacities (GGO) rapidly developed in the unilateral lung over 4 days despite the use of broad-spectrum antibiotics. Development of GGO was considered to be related to a nivolumab-mediated immune reaction. Corticosteroid was administered and the GGO subsequently disappeared. The present report focuses on the computed tomography diagnostic features of nivolumab-related pneumonitis. The accumulation of knowledge regarding various types of antiprogrammed death-1-related pneumonitis will lead to appropriate treatment for this newly emerging adverse event.

OBJECTIVES This study aimed to develop a prediction model for less invasive lesions of pathological Stage IA adenocarcinomas. METHODS We retrospectively evaluated 121 lesions from 114 patients with pathological Stage IA adenocarcinoma who underwent surgery after fluorodeoxyglucose positron emission tomography and high-resolution computed tomography. Less invasive lesions were adenocarcinoma in situ and minimally invasive adenocarcinoma. The 3D parameter, solid tumour ratio, was the volume ratio of the solid part to the whole tumour. The 2D parameter was the consolidation-to-tumour ratio. The maximum standardized uptake value (SUVmax) in fluorodeoxyglucose positron emission tomography was the metabolic parameter. A volumetric analysis programme semiautomatically measured these 3 parameters. The cut-off values were 0.5, 0.125 and 1.0 for the consolidation-to-tumour ratio, solid tumour ratio and SUVmax, respectively. Multivariable logistic regression analysis was used to select the prediction model parameters. RESULTS There were 34 (28.1%) less invasive lesions. A consolidation-to-tumour ratio

Gastroparesis is a challenging gastrointestinal complication of deceased-donor lung transplantation and heart-lung transplantation, but it has not been reported after living-donor lobar lung transplantation (LDLLT). To better understand this complication after LDLLT, we reviewed our institutional experiences. Among the 32 patients who survived for at least 3 months after LDLLT, five (16 %) developed symptomatic gastroparesis. All five patients had undergone bilateral LDLLT, and gastroparesis was diagnosed within 2 months after transplantation. Neither adult patients who received single lobar LDLLT nor pediatric patients who received either bilateral or single lobar LDLLT developed gastroparesis. Although gastroparesis-related symptoms improved after medical treatment in three patients, two patients died of complications related to gastroparesis. We conclude that gastroparesis can occur after LDLLT and may cause grave complications unless carefully managed.

OBJECTIVES: Recent studies suggest hypogammaglobulinemia (HGG) is frequently associated with infection after solid organ transplantation, although the effects of HGG after lung transplantation are not well recognized. We investigated the incidence and degree of HGG after lung transplantation and its association with infection. METHODS: A retrospective cohort study analysing pre- and post-transplant IgA, IgG and IgM levels and infectious events in patients undergoing living-donor lobar and cadaveric lung transplantation at Kyoto University Hospital between June 2008 and March 2013. RESULTS: Overall, post-transplant immunoglobulin (Ig) levels were significantly lower than pretransplant levels. In almost all patients who received transplants for bronchiolitis obliterans (BO) after haematopoietic stem cell transplantation (HSCT), interstitial lung diseases and bronchiectasis, post-transplant IgA and IgG levels decreased and were significantly lower than pretransplant levels; pre- and post-transplant IgA and pretransplant IgG levels were significantly lower in patients transplanted for BO after HSCT than in the others. Post-transplant IgG levels in patients transplanted for BO after HSCT also tended to be lower than those in the others, but not significantly. Nineteen of 29 patients had HGG after lung transplantation (65.5%) and had more infections than the normal gammaglobulinemia group, although there was no significant difference. Among them, 2 patients transplanted for BO after HSCTwith quite low HGG had severe pneumonia and finally died. CONCLUSIONS: Post-transplant Ig levels were significantly lower than pretransplant levels. Although without significant difference, HGG patients had more infections, above all, those with severe HGG transplanted for BO after HSCT could have lethal infections. Ig levels in HGG should be monitored carefully because severe HGG was associated with poor prognosis.

Objectives the objective of our study was to clarify survival and treatments in patients with incompletely resected thymoma. Methods between January 1991 and December 2012, 156 consecutive patients who underwent thymectomy with curative intent at Kyoto University Hospital, were evaluated retrospectively. Overall survival and progression-free survival were analyzed using the Kaplan-Meier method, comparing the complete resection group ( n = 141) with the incomplete resection group ( n = 15). Potentially relevant factors for overall survival and progression-free survival in patients with incompletely resected thymomas were analyzed using Cox proportional-hazard models. Results there was a significant difference in progression-free survival ( p = 0.0012) but not in overall survival ( p = 0.638) following thymectomy in the complete and incomplete resection groups. Adjuvant chemotherapy was performed in 6 (40%) patients and adjuvant radiotherapy in 6 (40%) in the incomplete resection group. In univariate analysis, younger age ( p = 0.073) showed a tendency for better overall survival, and adjuvant chemotherapy ( p = 0.071) showed a tendency for better progression-free survival. Conclusion our results suggest that patients with incompletely resected thymomas can achieve comparable overall survival to those with completely resected thymomas. Adjuvant chemotherapy for incompletely resected thymomas tends to improve progression-free survival.

Living-donor lobar lung transplantation (LDLLT) has been successfully performed in Japan. In LDLLT, the recipient usually receives one lower lobe from each of two donors; however, finding two ABO-matched donors is often difficult. Solid organ transplants from donors with minor ABO-mismatches can be complicated by hemolysis. We investigated the incidence of de novo anti-ABO antibody production and hemolysis in patients receiving LDLLT across minor ABO-mismatches. We evaluated 23 patients who underwent LDLLT between June 2008 and December 2011, including 11 patients who underwent minor ABO-mismatched transplantation. We measured the anti-A/B antibody serum titers, hemoglobin concentrations and indirect bilirubin levels. None of the patients showed any clinical signs of hemolytic anemia (mean follow-up period; 16 months). Two of the 11 patients (18 %) receiving minor ABO-mismatched LDLLTs showed a small amount of de novo anti-B antibodies for a transient period. These patients showed gradual progression of anemia, and weak de novo anti-A/B antibodies were detected with column agglutination technology. The patients received only 2 U of washed type O red blood cells; thereafter, the hemolytic anemia did not develop further in either case. LDLLT across minor ABO-mismatches results in the transient appearance of weak de novo anti-A/B antibodies with a low incidence; thus, this procedure can be a safe treatment.

The success of living-donor lobar lung transplantation (LDLLT) largely depends on donor outcome; but to date, no authors have studied health-related quality of life (HRQOL) of donors. We prospectively evaluated multidimensional outcomes before and 1 year after donor lobectomies. Patient-reported HRQOL, dyspnea, psychological status and sleep quality, and physiological pulmonary function were determined. All donors were alive without any limitations in their activities of daily living after 1 year. Postoperative pulmonary function was better than the estimated preoperative values; but, with respect to HRQOL, four of the eight subscales of the Medical Outcomes Study 36-item short form (SF-36) deteriorated significantly after donation. In addition, dyspnea assessed by the modified Medical Research Council scale also worsened significantly. In contrast, postoperative anxiety assessed by the Hospital Anxiety and Depression Scale significantly improved from baseline. The donors whose recipients died reported lower SF-36 scores with worsening sleep quality measured by Pittsburgh Sleep Quality Index. Thus, although postoperative pulmonary functions in donors were preserved, their HRQOL and dyspnea deteriorated postoperatively. Moreover, HRQOL and sleep quality were impaired in recipients who experienced poor outcomes. To capture the comprehensive outcomes in LDLLT donors after donation, patient-reported outcomes should be analyzed separately from physiological outcomes.

Lung transplantation (LTx) is an established therapy for end-stage lung failure. However, in Japan, the donor organ shortage is extremely severe compared with other developed countries, because of the strict Japanese Organ Transplantation Law. To maximize LTx opportunities in Japan, we have established a special donor evaluation and management system termed the medical consultant (MC) system. Data from 171 lung donor candidates registered in Japan from May 1998 to May 2012 were obtained and investigated in a retrospective manner. The candidates were separated into the non-MC-intervened and MC-intervened groups, and then data regarding the PaO2/FiO2 ratio, donation rate and organ survival rate were analyzed and compared between the groups. The PaO2/FiO2 ratio of the MC-intervened group was ameliorated from the time of first brain death diagnosis to organ harvest. Although the base condition of the MC-intervened group was significantly worse than that of the non-MC-intervened group, the donation rates showed no significant difference (0.64 and 0.66, respectively; p = 0.89). There was a difference in the organ survival rate between the non-MC and MC-intervened groups (5-year survival rates of 67.2 and 88.3 %, respectively; p = 0.16). The MC system used for organ donor evaluation and management in Japan has achieved acceptable interim results.

Postoperative recurrence in non-small cell lung cancer (NSCLC) reduces the life expectancy of patients. In this retrospective study, we investigated the prognostic factors in patients with postoperative brain metastases from surgical resected non-small cell lung cancer (NSCLC). We conducted a retrospective chart review of patients who had undergone resection for NSCLC between April 2004 and February 2009 and found 65 had experienced postoperative brain metastases by March 2010. We reviewed these patients for clinicopathological information, treatments and responses to treatment, and overall survival. The 5-year survival rate after the diagnosis of brain metastases was 15.4 %. Significantly favorable prognostic factors for patients after a diagnosis of brain metastases included female gender, adenocarcinoma, a small number (1–3) of brain metastases, no extracranial metastasis at the diagnosis of brain metastases, radiation treatment (whole-brain radiation and/or stereotactic irradiation), and local treatment [stereotactic irradiation and/or surgical operation (craniotomy)]. Furthermore, in patients with only brain metastases as the postoperative initial recurrence, the favorable positive prognostic factors included a small number (1–3) of brain metastases, adjuvant chemotherapy, chemotherapy (including adjuvant and other chemotherapy and excluding epidermal growth factor receptor–tyrosine kinase inhibitors), and local treatment. Our study found that the foregoing clinical characteristics in postoperative brain metastases and the administration of treatment contributed to patient life expectancy.

A 50-year-old man with hemoptysis, given a diagnosis of left upper lobe pulmonary aspergilloma with cavity and fungus ball by computed tomography. He has a history of typeⅠ diabetes mellitus due to traumatic injury of pancreas and underwent diaphragm plasty. Despite of systemic anti-fungal medication, symptom and radiological findings were not progressed and surgical intervention was planned. Before surgery we performed intercostal artery embolization, in order to minimize bleeding on dissecting adhesion between the chest wall and the lobe with aspergilloma. Left upper lobectomy with muscle-flap prombage was done safely with a blood loss of 450 ml. Postoperative course was favorable. Intercostal artery embolization with N-butyl-2cyanoacrylate is an effective way to minimize hemorrhage during surgical resection for pulmonary aspergillosis with sever adhesion.

A 6-year-old girl with idiopathic interstitial pneumonia successfully underwent living-donor right single-lobe lung transplantation from her mother. Her mother's right lower lobe was 207% bigger than her right chest cavity, and attempting chest closure caused significant compression and narrowing of the right pulmonary vein anastomosis, as assessed by transesophageal echocardiogram. Her chest was temporarily closed without rib approximation. The following day, her chest could be completely closed. The pulmonary vein anastomosis, confirmed by transesophageal echocardiogram, was now patent. Currently, 7 months after the transplantation, she is well without limitations.

We evaluated the effect of an extracellular phosphate-buffered lung preservation solution (EP-TU solution) on acute postoperative graft function and recipient survival in a Japanese series of cadaveric lung transplantation.The subjects were ten patients who received lung grafts preserved with EP-TU solution at three of four designated lung transplant centers between 2000 and 2005. Three of the patients underwent single lung transplantation and seven underwent bilateral lung transplantation. Postoperative graft function was evaluated by primary graft dysfunction (PGD) grade (0-3), arterial oxygen tension/inspired oxygen fraction (PaO(2)/FiO(2)) ratio, and the previously reported chest roentgenogram score (CRS, 0-4) during the first 48 h after intensive care unit admission. Survival rates were also calculated.The average graft ischemic times for the first and second grafts were 431 and 571 min, respectively. The average PGD grade ranged from 0.5 to 1.0 and the average PaO(2)/FiO(2) ratio ranged from 350 to 400 Torr during the 48 h. The average CRS was always under 1.0. Survival rates at 30 days and 5 years were 90 and 80%, respectively.EP-TU solution promoted excellent postoperative lung graft function and enhanced recipient survival rates, despite a long average preservation time.

Oncogenic gene mutations observed in lung adenocarcinomas, such as epidermal growth factor receptor (EGFR) and KRAS, have some predictive value for chemotherapeutic drugs or EGFR–tyrosine kinase inhibitors. However, the influence of these gene alterations on patients’ prognosis remains controversial. We retrospectively analyzed the tumors of 180 patients with completely resected pathological stage I–III lung adenocarcinoma which harbored either KRAS codon 12 mutation or EGFR gene mutations within exons 18–21 to investigate the impact of these gene mutations on the patients’ survival. Gene mutations were detected by established methods. Of 180 patients, 32 had KRAS codon 12 mutations (KRAS group), 148 had EGFR mutations within exon 18–21 (EGFR group). Pathological stage and operation mode were independent factors for disease-free survival. However, the EGFR group had better overall survival than the KRAS group (P = 0.0271). Cox proportional hazard model revealed pathological stage (P = 0.0001) and presence of EGFR gene mutations (P = 0.0408) were independent factors for overall survival. In survival after tumor recurrence, the EGFR group had a better median survival time (46.7 months) after recurrence than the KRAS group (26.0 months). In patients with completely resected lung adenocarcinomas, KRAS and EGFR gene mutation status of tumors was not associated with disease-free survival. However, the presence of an EGFR gene mutation boded well for the patient’s overall survival, and thus patients with EGFR mutations have a better prognosis than those with KRAS mutations.

Background We previously proposed calculating forced vital capacity (FVC) by the number of segments for size matching in living-donor lobar lung transplantation (LDLLT). The primary purpose of this study was to compare spirometry-obtained calculations of lower lobe volumes with three-dimensional (3D) computed tomography (CT) volumetric images. Our second goal was to compare the data of pulmonary function tests with CT volumetry in living lung donors. Methods Pulmonary function test, including FVC and total lung capacity (TLC), and 3D CT volumetry were performed pre-operatively in 21 healthy donor candidates for LDLLT. The relationship of 3D CT volumetric data and calculated volume of lower lobes by the number of segments was investigated. Also studied were 3D CT volumetric data in relation to FVC and TLC. Various pre-operative variables were analyzed retrospectively. Results According to 3D CT volumetry, the right and left lower lobe volume was 26.3% ± 2.9% and 22.6% ± 3.1% of the total lung volume, respectively. We found a significant, strong correlation between each lower lobe volume and the total lung volume. Because the calculated volumes of right and left lower lobes by the number of segments were 26.3% and 21.1%, respectively, our results implied that the volume of both lower lobes was accurately described by the number of segments. FVC was significantly associated with TLC and the total lung volume. Conclusions We confirmed that it would be justified to estimate graft FVC by the number of segments according to the CT volumetric data in LDLLT.

Objective Although double lung transplantation is performed more frequently for emphysema, single lung transplantation (SLT) continues to be performed owing to limited donor organ availability. Native lung hyperinflation (NLH) is a unique complication following SLT for emphysema. Three-dimensional computed tomography (3D-CT) volumetry has been introduced into the field of lung transplantation, which we used to assess NLH in emphysema patients undergoing SLT. The primary purpose of this study was to confirm the effectiveness of 3D-CT volumetry in the evaluation of NLH following SLT for emphysema. Methods In 5 emphysema patients undergoing SLT at Kyoto University Hospital, 3D-CT volumetry data, pulmonary function test results, and clinical and radiological findings were retrospectively evaluated. Results Three patients did not develop a significant mediastinal shift, whereas the other 2 patients developed a mediastinal shift. In the 3 patients without a mediastinal shift, 3D-CT volumetry did not show a significant increase in native lung volume. These patients had a history of sternotomy prior to lung transplantation and firm adhesion on the mediastinal side was detected during lung transplantation. One of 2 patients with a mediastinal shift developed severe dyspnea with significantly decreased pulmonary function, and 3D-CT volumetry showed a significant increase in the native lung volume. However, the other patient did not show any dyspnea and his native lung volume decreased postoperatively (preoperatively to 6 months postoperatively: +981 mL and −348 mL, respectively). Conclusion Although bilateral lung transplantation has become preferable for emphysema patients owing to postoperative NLH with SLT, patients with a history of sternotomy prior to lung transplantation might be good candidates for SLT. 3D-CT volumetry may be a useful method for detection of NLH.

Background Stereotactic body radiotherapy (SBRT) has emerged as a curative treatment for medically inoperable patients with early-stage non-small cell lung cancer (NSCLC). Since NSCLC recurs locally in 10% of the patients treated with SBRT, salvage lung resection after SBRT may be considered in these cases. To further understand the indications for salvage surgery and the pathogenesis of tumor recurrence in these patients, we retrospectively reviewed cases treated at our institution. Methods SBRT has been performed in patients with early-stage NSCLC at Kyoto University Hospital. We encountered 5 patients who underwent salvage lung resection for NSCLC after SBRT. Results All the patients were initially operable, but they chose SBRT. After SBRT, the tumors shrank initially in all patients, but increased in size within 18 months of SBRT in the case of 4 patients. During surgical extirpation, we did not find any significant SBRT-related adhesions in any of the patients. Conclusions We have successfully treated 5 patients who underwent salvage lung resection for early-stage NSCLC after SBRT. We found that surgical resection was feasible after SBRT.

Background. Functional evaluation of potentially damaged lungs donated after cardiac death is crucial for widespread clinical transplantation. To date, the mean weight of animals used in studies of ex vivo lung perfusion (EVLP) has been 60 kg; however, in the clinical setting, donor weight may be greater. Objective. To investigate EVLP using lungs from large pigs (mean weight, 115 kg) to simulate human adult lungs donated after cardiac death. Materials and Methods. Five heart-lung blocks were obtained at 20 minutes after death at the slaughterhouse. The lungs were flushed and preserved on ice for 6 hours before being connected to an ex vivo lung circuit, and were perfused for at least 2 hours. Results. In all cases, perfusion was sustained for at least 2 hours. Mean (SEM) final flow rate was 4.9 (0.1) L/min, pulmonary artery pressure was 14.8 (1.7) mm Hg, and oxygen tension/fraction of inspired oxygen was 518.0 (18.0) mm Hg. The shunt fraction was 20.5% (4.0%). Histologic analysis demonstrated no significant pulmonary edema at the end of perfusion. Conclusion. We successfully completed EVLP using lungs from large pigs.

BACKGROUND: For patients with a thoracic malignancy whose peripheral veins are not suitable for blood access for chemotherapy, we evaluated a totally implantable central venous access port, in which the port is implanted in the ulnar side of the arm and the catheter is introduced via the basilic vein into the superior vena cava (TIAP-BV). METHODS: Twenty-five patients (21 with lung cancer, 2 with malignant pleural mesothelioma, and 2 with thymoma) receiving TIAP-BV were included. Indications, surgical complications, and long-term complications were analyzed. RESULTS: Indications for TIAP-BV were: chemotherapy (17 patients) and chemotherapy with parenteral nutrition (8 patients). The following surgical complications occurred: arrhythmia due to misplacement of the tip of catheter (1 patient); intraoperative conversion from the left to right arm (2 patients); and hematoma at the implantation site (1 patient). Short-term problems were: death 1 week after implantation without the use of TIAP-BV (2 patients). Long-term complications were: skin ulcer at the port site (1 patient); early removal of TIAP-BV because of port site infection (1 patient); catheter occlusion (1 patient); and venous thrombosis of basilic vein (2 patients). In the 22 patients who did not die early or have the device withdrawn early, the median duration of TIAP-BV use was 7 months (range, 1 to 20 months) without any break to the port system, leakage of drugs, or catheter-related infections. CONCLUSION: TIAP-BV can be employed for long-term use for chemotherapy and parenteral nutrition. However, a patient's expected prognosis and infectious disease status at the time of implantation surgery should be considered before the surgery proceeds.

Background and objectives Metastatic breast cancer has been defined as a systemic disease. The discussion concerning the resection of lung metastases in patients with breast cancer is controversial. To confirm the role of resection of pulmonary metastases from breast cancer and to identify possible prognostic factors, we reviewed our institutional experience. Methods Between 1991 and 2007, 41 patients with pulmonary metastases from breast cancers underwent complete pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary tumors. Various perioperative variables were investigated retrospectively to confirm the role of metastasectomy and to analyze prognostic factors for overall survival after metastasectomy. Results All patients were female with a median age of 55 years (range, 35–81 years). The overall survival rate after metastasectomy was 51% at 5 and 10 years. On multivariate analysis, fewer than four pulmonary metastases and a disease-free interval of more than 3 years were significantly favorable prognostic factors for overall survival ( p = 0.023 and 0.024, respectively). Conclusions The current practice of pulmonary metastasectomy for breast cancers in our institution was well justified. Pulmonary metastasectomy in patients with previous breast cancer might be justified when fewer than four pulmonary metastases or a disease-free interval of more than 3 years.

Thioredoxin is a ubiquitous protein with anti-oxidative, anti-apoptotic, and anti-inflammatory effects. It was reported [Fukuse T, Hirata T, Yokomise H et al. Attenuation of ischaemia reperfusion injury by human thioredoxin. Thorax 1995; 50: 387-391] that rhTRX protected lungs from ischemia-reperfusion injury as a radical scavenger; however, the mechanism was not elucidated. Therefore, we investigated the effect of perfusion and inhalation of rhTRX, and the associated mechanisms, by analyzing the concentrations and molecular states of the perfused rhTRX.Perfusion and inhalation studies of rhTRX were conducted with an isolated rat-lung perfusion model. The heart-lung block was perfused for 15 min and subsequently exposed to a 55-min ischemia followed by a 120-min reperfusion. Pulmonary artery pressure, weight gain, dynamic airway resistance, pulmonary compliance, and tidal volume were measured continuously. The concentrations and molecular states of the perfused rhTRX were measured.A 350-microg/ml perfusion of rhTRX decreased post-ischemic pulmonary artery pressure (P0.05), while a 200-microg/ml perfusion did not. Throughout the experiment, the rhTRX concentrations were constant, and the rhTRX molecules were mostly dimeric. The inhalation of rhTRX showed adverse effects on the pulmonary function compared with the control group (P0.05).A 350-microg/ml perfusion, but not inhalation, of rhTRX protected rat lungs from ischemia-reperfusion injury. rhTRX was effective in dimeric form without transit to the lung tissue. rhTRX may be effective by some mechanism other than radical scavenging.

Introduction: Management of pulmonary metastasis of non-small cell lung cancer (NSCLC) remains controversial. We reviewed our surgical treatment for pulmonary metastasis of NSCLC. Methods: Seventy-six patients with pulmonary metastasis of NSCLC underwent pulmonary resections in two institutes during the past 10 years. Eighteen patients with simultaneous same lobe metastasis as the primary lesion underwent mostly lobectomies. Sixteen patients with simultaneous different lobe metastasis underwent combined margin-free resections. Forty-nine pulmonary metastasectomies were performed in 42 patients with recurrent lung cancer. Overall survival and disease-free survival in each group were examined, and factors affecting survivals were investigated. Results: In the patients with the same lobe metastasis 5-year survival was 79.6%, and median and 5-year disease-free survivals were 39.1 months and 41.3%. In the patients with simultaneous different lobe metastasis median survival and 5-year survival were 37.7 months and 30.7%, and median and 5-year disease-free survivals were 13.3 months and 12.5%, respectively. Multiple pulmonary metastasis and mediastinal node metastasis were identified as significant factors affecting survivals. In the patients with recurrent pulmonary metastasis median survival and 5-year survival were 40.0 months and 34.8%, and median and 5-year disease-free survivals were 23.7 months and 14.4%, respectively. Node metastasis, higher age, and shorter interval from the prior resection were identified as significant factors affecting survivals. Conclusions: These findings suggest that the simultaneous same lobe metastasis is under the same indication for the primary lesion, and that the simultaneous different lobe metastasis and recurrent pulmonary metastasis should be removed in selected patients.

Pulmonary metastasectomy for colorectal carcinoma is a well-accepted procedure; however, reports on indications and prognostic factors are inconsistent. This study was designed to clarify a role for resection of pulmonary metastases for such tumors and to define the patients who benefit from pulmonary metastasectomy.Between 1990 and 2007, 84 patients with pulmonary metastases from colorectal carcinomas underwent curative pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary tumors. Various perioperative variables were investigated retrospectively to confirm a role for metastasectomy and to analyze prognostic factors for overall survival and disease-free survival after metastasectomy.Overall survival rate after metastasectomy was 60.5% and 48.4% at 5 and 10 years, respectively. Disease-free survival rate was 34.4% and 30.6% at 5 and 10 years after pulmonary resection, respectively. On multivariate analysis, patients with unilateral pulmonary metastasis presented a significantly favorable overall survival (P = 0.045). In contrast, there was no significant prognostic factor for disease-free survival.Current practice of pulmonary metastasectomy for colorectal carcinoma in our institution was well justified. Our study confirmed that unilateral pulmonary metastasis was significantly relevant to a better prognosis.

Background: Factors affecting recurrence and survival after pulmonary resection for metastatic osteosarcomas are controversial. To confirm a role for resection of pulmonary metastases for such tumors, we herein reviewed our institutional experience. Methods: Between 1989 and 2007, 23 patients with pulmonary metastases from osteosarcomas of the extremities underwent pulmonary resection. Various perioperative variables were investigated retrospectively to confirm a role for metastasectomy and to analyze prognostic factors for overall survival and disease-free survival after metastasectomy. Results: Overall survival rate after metastasectomy was 31% at 5 years. Disease-free survival rate was 19% at 5 years after pulmonary resection. On multivariate analysis, patients with less than five pulmonary metastases and patients without pulmonary metastases identified during pre- and postoperative chemotherapy presented significantly favorable overall survival (p = 0.015 and 0.0082, respectively). Furthermore, the number of pulmonary metastases less than five was the only significantly favorable prognostic factor for diseasefree survival on univariate analysis (p = 0.0055). Conclusions: Current practice of pulmonary metastasectomy for osteosarcomas in our institution was well justified. The number of pulmonary metastases more than five and the advent of pulmonary metastases during pre- and postoperative chemotherapy seemed relevant to a worse prognosis. # 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs; however, few data have been available about lung metastasectomy for hepatocellular carcinoma. To confirm the role for resection of pulmonary metastases for such tumors, we reviewed our institutional experience.Between 1993 and 2005, 12 patients with pulmonary metastases from hepatocellular carcinomas underwent complete pulmonary resection. All patients had undergone curative resection of their primary hepatocellular carcinomas and also had obtained or had obtainable locoregional control of their primaries. Various perioperative variables were investigated retrospectively to analyze the possible prognostic factors for overall survival and pulmonary metastases-free survival after pulmonary metastasectomy.Nine patients were male and three were female (median age, 53 (range, 43-80) years). Overall survival rate after metastasectomy was 80.8%, 57.7%, and 28.9% at 1, 2, and 5 years, respectively. Pulmonary metastases-free survival rate was 64.2%, 32.1%, and 21.4% at 1, 2, and 5 years, respectively. Five patients presented recurrences in the remaining liver before pulmonary metastases, but hepatic recurrences at this interval did not affect an overall survival after pulmonary metastasectomies. Two patients had undergone living-related liver transplantation. The maximum tumor size of the pulmonary metastasis3 cm was the only favorable prognostic factor for overall survival (P = 0.0006), whereas there was no significant prognostic factor for pulmonary metastases-free survival.Pulmonary metastasectomy for hepatocellular carcinoma in selected patients was well justified when the maximum tumor size was3 cm.

Pulmonary metastasectomy has become the standard therapy for various metastatic malignancies to the lungs; however, little data have been available about lung metastasectomy for head and neck cancers. To confirm a role for resection of pulmonary metastases for such tumors, we reviewed our institutional experience. Between 1991 and 2007, 20 patients with pulmonary metastases from head and neck cancers underwent complete pulmonary resection. All patients had obtained or had obtainable locoregional control of their primary head and neck cancers. Various perioperative variables were investigated retrospectively to analyze the prognostic factors for overall survival and disease-free survival after metastasectomy. Of the 20 patients, 10 (50%) had squamous cell carcinoma, 7 (35%) had adenoid cystic carcinoma, and 3 had miscellaneous carcinomas. The median disease-free interval from the time of treatment of the head and neck primary cancers to the development of pulmonary metastases was 27 months. Overall survival rate after metastasectomy was 59.4% at 5 years and 47.5% at 10 years, respectively. Disease-free survival rate was 25.0% at 5 years after pulmonary resection. A disease-free interval equal to or longer than 12 months was a significantly favorable prognostic factor for both overall survival and disease-free survival (p = 0.02 and 0.01, respectively). Patients with squamous cell carcinoma and male sex showed a worse overall survival (p = 0.04 and 0.03, respectively). The current practice of pulmonary metastasectomy for head and neck cancers in our institution was well justified. A disease-free interval equal to or longer than 12 months, nonsquamous cell carcinoma, and female sex might be relevant to a better prognosis.

The shortage of lung donors and ischemia-reperfusion injury following transplantation have been grave problems in lung transplantation (LTx). One of the most important strategies to solve these problems is the development of effective and highly reliable methods for lung preservation. Therefore, we developed a new organ preservation solution, namely, the extracellular-type trehalose-containing Kyoto (ET-Kyoto) solution. Here we report the first experience of clinical application of ET-Kyoto solution for cadaveric LTx. The recipient was a 38-year-old man with pulmonary emphysema. The donor was a 51-year-old male current smoker with a smoking history of 62 pack-years. The ventilated donor's PaO(2) was 340 Torr (FiO(2) = 1.0). The pulmonary vasculature was flushed with ET-Kyoto solution supplemented with nitroglycerine and dibutyryl cAMP. The recipient underwent bilateral sequential LTx on cardiopulmonary bypass. The ischemic time was 544 and 613 minutes for the left and right lung, respectively. PaO(2) (FiO(2) = 1.0) was 385 Torr immediately after reperfusion. The donor lung was so large that bilateral partial resections were performed at 413 minutes (right) and 348 minutes (left) after reperfusion. On histopathologic examination of the resected transplanted lungs the structure was almost normal. Postoperatively, PaO(2) (FiO(2) = 1.0) was over 400 Torr with or maximum of 526 Torr. The clinical course was almost uneventful. In conclusion, ET-Kyoto solution may be safely applied in clinical cadaveric LTx with extended donor lungs and relatively long ischemic times. Functional and histopathological efficiency of ET-Kyoto solution was confirmed. Longer preservation times with preserved quality using ET-Kyoto solution would increase the donor pool and enable semielective LTx.

Objective: To improve the postoperative results of limited resection for small lung cancer, we have developed a new operative method, pulmonary artery-guided segmentectomy. This resection begins with identification of the pulmonary arterial branches involved in the tumor, then the pulmonary tissue is divided along the pulmonary arteries (i.e. guided by pulmonary arteries) from the hilum toward the periphery by electrocautery. The advantages of this method include the facilitation of securing adequate margin from the tumor, and the feasibility of intralobar lymph node dissection during operation. To examine the efficacy of the new method of segmental resection, we retrospectively reviewed 74 cases of T1N0M0 disease who underwent the pulmonary artery-guided segmentectomy. Methods: From 1993 to 2000, 74 patients with pathological T1N0M0 lung cancer were treated by the pulmonary artery-guided segmentectomy. Forty-one patients (55.4%) who underwent the segmentectomy had been considered suitable candidates for lobectomy (intentional resection group). The other 33 patients (44.6%) were considered poor candidates for lobectomy because of poor cardiopulmonary reserve (compromised resection group). Results: The overall survival rate at 5 years was 82.0%. The 5-year survivals in the intentional and the compromised resection groups were 81.6 and 77.6%, respectively, and no significant differences were detected between the groups. According to tumor size, the 5-year survival rate for patients with tumors of 20 mm or smaller (92.9%, n ¼ 53) was higher than that for the patients with tumors of 21‐30 mm (63.0%, n ¼ 21), but the difference did not reach statistical significance. Median follow-up time of 27.0 months revealed eight locoregional recurrences and four deaths due to lung cancer. Sixty-three patients (85.1%) are alive with no evidence of disease, and six patients (8.1%) are alive with recurrent disease. Locoregional recurrences occurred in one of 53 patients (1.9%) with tumors 20 mm or smaller and in seven of 21 patients (33.3%) with tumors 21‐30 mm, the difference being statistically significant (P , 0:01). Conclusions: Our intermediate results demonstrated that the new pulmonary artery-guided segmentectomy could be an alternative method for selected patients with small lung cancer, particularly with tumors 20 mm or smaller in diameter. q 2002 Elsevier Science B.V. All rights reserved.

Background Living-donor lobar lung transplantation (LDLLT) recipients often have hypercapnia preoperatively, which confers a risk of worsened hypercapnia intraoperatively. We reviewed our experience with continuous carbon dioxide partial pressure (PtcCO2) monitoring in LDLLT to evaluate its accuracy and feasibility. We also assessed preoperative and intraoperative carbon dioxide levels in LDLLT recipients. Material and methods Twenty-six LDLLT recipients without pulmonary hypertension underwent preoperative nocturnal and intraoperative PtcCO2 monitoring, determined with a TOSCA-500 monitor. Results Maximal preoperative nocturnal PtcCO2 (72.7 ± 19.3 mmHg) was significantly correlated with preoperative resting arterial carbon dioxide partial pressure (PaCO2; 55.1 ± 11.6 mmHg, r(2)=0.84). PtcCO2 was more correlated with PaCO2 (range, 39-192 mmHg) during LDLLT (r(2)=0.93) than with end-tidal carbon dioxide partial pressure (r(2)=0.38). Intraoperative continuous PtcCO2 monitoring was useful for evaluating real-time carbon dioxide levels. Intraoperative PtcCO2 did not exceed maximal preoperative nocturnal PtcCO2 in 13 recipients (50%) but temporarily exceeded it in 11 recipients (42%). PtcCO2 was further elevated in 2 recipients (8%) requiring the early establishment of cardiopulmonary bypass. There were no complications related to PtcCO2 monitoring. Conclusions PtcCO2 monitoring in LDLLT recipients is useful as a means for determining intraoperative carbon dioxide levels, which increase dramatically and can be predicted preoperatively and assessed in a timely manner.

Adjuvant vinorelbine and cisplatin chemotherapy is recognized as a standard regimen for patients with completely resected stage II and III non-small cell lung cancer (NSCLC). However, efficacy of adjuvant chemotherapy in Japanese phase III trials with cisplatin-containing regimen has been controversial, and data are limited on the long-term outcome of adjuvant vinorelbine and cisplatin chemotherapy for NSCLC patients.This was a single-arm phase II study in patients with completely resected pathological stage II or III NSCLC, who had not received prior chemotherapy or radiotherapy. Patients received 4 cycles of vinorelbine [25 mg/m(2) of body surface area (BSA)] and cisplatin (40 mg/m(2) of BSA) on days 1 and 8, every 4 weeks. Primary end point was the 3-year relapse-free survival; secondary end points were overall survival and safety.Between December 2006 and January 2011, 60 patients (40 men and 20 women, median age 64 years) were enrolled; all patients were evaluable for survival and safety. Three-year relapse-free survival rate was 55.0 % (95 % confidence interval 42.4-67.6 %). Three- and five-year overall survival rates were 83.3 and 77.8 %, respectively. There were no chemotherapy-related deaths, and adverse effects were acceptable.Adjuvant vinorelbine and cisplatin chemotherapy was safe and showed a valid relapse-free survival rate. This regimen could be used as a standard regimen and deserves to be a control arm of trials on adjuvant chemotherapy in the Japanese NSCLC patient population.

Surgical lung biopsy (SLB) by videothoracoscopy for diffuse interstitial lung diseases is recommended for detailed diagnosis. Because substantial mortality and morbidity are associated with this procedure, its safety and diagnostic yield should be validated. Sixty-four patients with diffuse interstitial lung disease who received SLB by videothoracoscopy between 2007 and 2013 were retrospectively analyzed for mortality, surgical complication, and diagnosis. Criteria for the procedure included patients

This retrospective study aimed to determine prognostic factors associated with postrecurrence survival of completely resected non-small cell cancer patients with postoperative recurrence. Characteristics, treatment modality, and postrecurrence survival of 234 patients (157 males and 77 females, mean age at recurrence: 68.7 years, 152 adenocarcinomas and 82 non-adenocarcinomas), who underwent complete resection for non-small cell lung cancer between 2003 and 2009 at our hospital and experienced recurrence, were analyzed for prognostic factors. Cox proportional hazard model was applied for multivariate analysis. Among 234 patients, the median survival time after the diagnosis of recurrence was 21 months, and the 5-year postrecurrence survival rate was 19.9 %. Eastern Cooperative Oncology Group Performance Status (ECOG PS) (hazard ratio [HR]: ECOG PS-0/PS-1/PS-2 = 1/3.313/7.622), time to recurrence after surgery (HR: >2 years/1–2 years/

SummaryObjectivesMycobacterium peregrinum is a species included in the Mycobacterium fortuitum complex, a member of the group of rapidly growing non-tuberculous mycobacteria (RGM). Only a few cases of infection with M. peregrinum have been reported, and no relevant review has been published.MethodsFollowing the treatment of a patient with M. peregrinum infection after plastic surgery, we undertook a review of the literature of previously reported cases of M. peregrinum infection.ResultsTen previously reported cases were identified. Like other cases of the M. fortuitum complex infections, the majority of M. peregrinum infections were related to surgical site infections and catheter-related infections. In the literature, most of the antibiotic regimens were based on a combination of quinolones with various antibiotics, and the duration of treatment ranged from 6 weeks to 4 months.ConclusionThe fact that the optimal treatment for M. peregrinum infection has not yet been established has resulted in the use of a diverse range of therapies. It is important that clinicians carefully review each case so that a more appropriate treatment for M. peregrinum infections can be determined.

We report here on the successful treatment for right ventricular outflow tract obstruction after bilateral lung transplantation in a patient with primary pulmonary hypertension. A 31-year-old female patient with primary pulmonary hypertension underwent successful bilateral lung transplantation. She had a pressure gradient of 30 mmHg through the right ventricular outflow tract one week after transplantation, but was successfully treated with atelenol and disopyramide. Long-term follow-up cardiac catheterization did not show any significant right ventricular outflow tract obstruction. The actual cause of the right ventricular outflow tract obstruction remained unknown, but longstanding pulmonary hypertension might have induced significant structural changes in the heart, such as right ventricular hypertrophy and enlargement.

Transverse thoracosternotomy is the standard approach for bilateral lung transplantation (BLT), but all measures must be taken to prevent breakdown of the sternal wound. We report a case of sternal dehiscence with subcutaneous and peristernal air collections, which occurred 1 month after BLT, performed through a transverse thoracosternotomy, in a 38-year-old man. Surgical exploration revealed that the sternal wires had cut through the bone, causing air leakage of both lungs. We repaired the injured lungs and reapproximated the sternum; however, a pseudo-joint of the sternum developed postoperatively. We report the clinical course of this post-transplant patient to highlight the impact and management of sternal dehiscence.

During a routine health care evaluation, an abnormal shadow was detected in the chest roentgenogram of a 35-year-old man. Chest computed tomography scanning showed a nodule, approximately 3 cm in diameter, in the left S6 pulmonary segment with surrounding infiltration. Bronchoscopy revealed obstruction of the left B6c bronchus by a tumor, for which biopsy was done but no definitive histologic diagnosis could be made. Then, left lower lobectomy was performed, and the tumor was diagnosed as a pulmonary sclerosing hemangioma. A mediastinal lymph node (no. 7) showed some metastatic tumor cells. As lymph node metastasis from pulmonary sclerosing hemangioma is very rare, we herein report the details of our case.

We performed emergency living-donor lobar lung transplantation (LLTx) successfully in a 24-year-old woman with end-stage pulmonary and massive abdominopelvic lymphangioleiomyomatosis (LAM). Preoperatively, her respiratory condition was critical, but abdominopelvic lesions had been well controlled with medication. No LAM patients with massive abdominopelvic lesions as in the present case have been reportedly treated by LLTx previously. The present case demonstrates that LLTx can be a therapeutic option for end-stage pulmonary LAM with massive abdominopelvic involvement.

Living-donor lobar lung transplantation (LDLLT) is an established therapy for patients with end-stage lung disease, but living-donor lobar lung retransplantation (re-LDLLT) is rarely reported. We previously reported a case of unilateral antibody-mediated rejection after LDLLT in the presence of newly formed donor-specific antibodies against a right-lobe donor. The same patient developed contralateral bronchiolitis obliterans, resulting in bilateral bronchiolitis obliterans, but re-LDLLT was successful. Pathological findings of the explanted lungs were consistent with the clinical course of the patient. One year after re-LDLLT, the patient is doing well without any anti-human leukocyte antigen antibodies. Four lobes from four different donors were transplanted in this patient. The first two lobes were rejected eventually, but the two lobes implanted later presented no signs of rejection at least for 1 year after the transplant. Herein, we report this rare case and compare the clinical course and pathological findings.

We report the case of a 31-year old woman with recurrence of left diaphragmatic eventration 3 years after a previous surgery for this condition. At the initial occurrence, she had experienced dyspnoea on exercise and subsequently underwent laparoscopic plication of the diaphragm with an endo-stapler at a local hospital. Immediately after the operation, the diaphragm was torn and the intestine entered the thorax. Therefore, plication involving sewing was performed. Then, 3 years later, the patient again experienced dyspnoea and was diagnosed as having recurrence of left diaphragmatic eventration. Observation under thoracoscopy revealed that the centre of the left diaphragm was thin but not torn. We reconstructed the left diaphragm with an elongated polytetrafluoroethylene sheet on the naive diaphragm. The patient was discharged from our hospital 5 days after surgery. Her respiratory function improved and she has not experienced recurrence.

Background We evaluated postoperative respiratory management of living donor lobar lung transplantation (LDLLT). Methods Perioperative variables were reviewed in 21 patients who underwent LDLLT at our institution. Recipients were kept intubated for at least two d after LDLLT to maintain optimal expansion of the implanted lobes. Subsequently, if weaning from artificial ventilation could be tolerated, extubation was considered with the assistance of non-invasive ventilation (NIV). If this could not be tolerated, early tracheostomy was considered. Results All 21 recipients were weaned from artificial ventilation. Twelve patients underwent tracheotomy 4.4 ± 1.8 d after LDLLT and were weaned from artificial ventilation 24.3 ± 17.0 d after LDLLT. Eleven patients were extubated 3.6 ± 1.7 d after LDLLT with NIV, but two of them were reintubated, and finally weaned from artificial ventilation via tracheostomy. Excluding these two patients, NIV was required for 3.8 ± 3.9 d after extubation. The early postoperative course was significantly eventful in patients with tracheostomies, and artificial ventilation, ventilatory support, and intensive care unit stays were longer. Twenty patients (95%) showed survival at 24.4 ± 13.4 months of follow-up. Conclusions Postoperative respiratory management with NIV and early tracheostomy were useful after LDLLT.

Living-donor lobar lung transplantation (LDLLT), unlike deceased donor lung transplantation, often involves a wide range of size discrepancies between donors and recipients. The aim of this study was to evaluate the function of donor lung grafts in the recipient thorax in 14 cases of bilateral LDLLT involving 28 successfully transplanted lower-lobe grafts. Pulmonary function tests and three-dimensional computed tomography (3D-CT) volumetry were performed perioperatively. According to 3D-CT size matching, donor graft volumes ranged from 40% to 161% of the hemilateral thoracic volumes of the recipients. Graft forced vital capacity (FVC) values increased over time, reaching 102 ± 39% of preoperatively estimated values at 12 months postoperatively. Graft volumes also increased over time, reaching 120 ± 38% of the original values at 12 months postoperatively. Undersized donor grafts expanded more after LDLLT than oversized donor grafts, producing greater FVC values than those estimated preoperatively, whereas oversized donor grafts became inflated to their original size and maintained FVC values that approached the preoperative estimates. Thus, donor grafts were found to overinflate or underinflate to the extent that they could preserve their native function in the new recipient's environment.