Bilateral Cardiac Sympathetic Denervation for Treatment-Resistant Ventricular Arrhythmias in Heart Failure Patients with a Reduced Ejection Fraction

The sympathetic nervous system plays an important role in life-threatening ventricular arrhythmias (VAs). Bilateral cardiac sympathetic denervation (BCSD) is performed for refractory VAs. We sought to assess our institutional experience with BCSD in managing treatment-resistant monomorphic ventricular tachycardia (MMVT) in heart failure patients with a reduced ejection fraction (HFrEF).Four patients with HFrEF (EF 30.0 ± 8.2%, New York Heart Association [NYHA] class IV 1) underwent BCSD for MMVT (VT storm 3, repetitive VT requiring implantable cardioverter defibrillator [ICD] therapy 1) refractory to antiarrhythmic drugs, catheter ablation and ICD therapy. BCSD was effective for suppressing VT in 3 patients for whom deep sedation was effective for suppressing VT. One patient remained alive after 14 months of follow-up without episodes of VT. One patient died of acute myocardial infarction before discharge and 1 patient died from unknown cause at 3 days post-discharge. In contrast, BCSD was completely ineffective for suppressing VT in a patient with NYHA class IV for whom deep sedation and stellate ganglion block were ineffective. This patient died on the 10th post-CSD day, despite left ventricular assist device implantation. In all cases, BCSD was successfully performed without procedure-related complications.Despite the limited number of cases, our results showed that BCSD in patients with HFrEF suppressed refractory MMVT in acute-phase except for a patient with NYHA class IV; however, the prognoses were not good. BCSD may be a treatment option at an earlier stage of NYHA and a bridge to orthotopic heart transplantation, even if BCSD is effective for suppressing VAs.

Uniportal thoracoscopic left posterior basal segmentectomy using a posterior approach

Posterior basal (S10) segmentectomy is one of the most challenging (and uncommon) types of pulmonary segmentectomy. Here, we present two key tips for facilitating a uniportal operation. The first is a full understanding of the relative locations of the pulmonary vessels and bronchi (as revealed by preoperative three‐dimensional computed tomography/broncho‐angiography), and the other is the use of “suction‐guided stapling” to dissect and divide the peripheral pulmonary vessels and bronchi. We describe the successful postoperative course of a patient who was so treated.

En bloc resection of the left upper lobe and the anterior basal segment of the lower lobe via a uniportal thoracoscopic approach for a dense fissure

Unidirectional dissection including a fissureless technique is a reasonable procedure for performing uniportal thoracoscopic major pulmonary resections because the angulation of the inserted surgical instruments or a thoracoscope via a single small incision is extremely limited. This type of procedure is considered useful for many types of anatomical pulmonary resections via a uniportal approach. In this video tutorial, which illustrates a more complicated case, we show en bloc resection of a left upper lobe and anterior basal segment (S8) using unidirectional dissection via a uniportal thoracoscopic approach for a patient with a dense fissure.

Preoperative Simulation of Thoracoscopic Segmentectomy

When performing thoracoscopic pulmonary segmentectomy, we sometimes encounter a non-palpable malignant tumor located near the intersegmental plane that we had planned to divide. In such a situation it can be difficult to ensure a sufficient surgical margin. To overcome this problem, we now perform preoperative simulation using the Ziostation2 (Ziosoft, Tokyo, Japan) to calculate the surgical margin. This yields margins of at least 20 mm; the discrepancy between the virtual and actual surgical margins is always less than 5 mm.

Comparison of stapler and electrocautery for division of the intersegmental plane in lung segmentectomy

Background

We retrospectively compared the use of a stapler and electrocautery for division of the intersegmental plane during pulmonary segmentectomy.

Methods

We enrolled 156 patients who underwent pulmonary segmentectomy in our department between March 2006 and August 2020. The patients were divided into electrocautery (n=62) and stapler (n=94) groups based on the device used to divide the intersegmental plane. Patient characteristics, perioperative outcomes, and ratios of actual (calculated using software) to predicted (calculated by counting the resected segments) lung volumes were compared between the two groups. Additionally, we used multivariate analysis to identify the factors that contributed to the incidence of postoperative air leakage after cut-off value was set by receiver operating characteristic (ROC) curve analysis. Moreover, a subset analysis was performed based on the type of segmentectomy (common or uncommon). Common segmentectomies included resection of the basilar or superior segment of the lower lobe, or lingular or upper division of the left upper lobe; all other segmentectomies were classified as uncommon.

Results

Compared to the electrocautery group, the stapler group had shorter operative times (P=0.0027), duration of postoperative drainage (P=0.00037), and duration of postoperative hospitalization (P=0.0021). Moreover, incidence of postoperative ≥3 days drainage was significantly reduced in the stapler group (P=0.003). There were no significant differences between the stapler and electrocautery groups in the actual:predicted lung volumes at 6 months (1.01 and 1.04, respectively; P=0.28) or 12 months (1.06 and 1.07, respectively; P=0.68) after surgery. Preoperative lung volume was significantly correlated with preoperative vital capacity (VC) (γ=0.69; P<0.001) and forced expiratory volume in 1 second (FEV₁) (γ=0.48; P<0.001). The multivariate analysis indicated that the use of stapler for division of intersegmental plane was the only factor that contributed to reducing the incidence of postoperative ≥3 days drainage (P=0.0027, odds ratio: 0.23, 95% CI: 0.086–0.597). In a subset analysis of uncommon segmentectomy, there were no significant differences among the groups in most perioperative results.

Conclusions

Compared to electrocautery, the use of a stapler for division of the intersegmental plane was associated with better perioperative outcomes, especially reduction of postoperative drainage time, and similar postoperative remnant lung volumes and function.

Differentiation between staple line granuloma and recurrence after sublobar resection for primary lung cancer

Background

The use of sublobar resection for early-stage lung cancer or frail cases that cannot tolerate radical surgery for primary lung cancer has been increasing. This study aimed to identify the frequency, shape, and course of staple line thickening and granuloma formation after sublobar resection for primary lung cancer, and to identify factors that help distinguish them from recurrent cancer cases.

Methods

The medical records of 64 patients who underwent sublobar resection for primary lung cancer from January 2012 to December 2017 at our institution were retrospectively reviewed. Computed tomography (CT) images taken every 6 months for at least 3 years after surgery were reviewed, and the postoperative course was examined.

Results

Staple line thickening at the time of the first CT scan after surgery was observed in 43 cases (67.2%). Of them, linear thickening was seen in 31 cases (72.1%), and nodular thickening was seen in 12 cases (27.9%). Of these 43 cases, 25 cases were decreased, 8 cases were unchanged and 10 cases showed a tendency to progress during the follow-up period. Of the 64 cases, 7 (10.9%) had staple line recurrence. Staple line recurrence was significantly correlated with vascular invasion (P=0.015), surgical margin (P=0.013), nodular thickening (P<0.001) and a tendency to show progressive thickening (P<0.001).

Conclusions

Staple line thickening was observed in many cases of sublobar resection, and most of them were linear thickening. Staple line recurrence should be suspected if nodular thickening appears and shows a tendency to progress.

[Recurrent Postoperative Lung Cancer with Tumor Shrinkage after Discontinuation of Pembrolizumab-A Case Report]

Our patient was a 41-year-old man with non-small cell lung cancer of grade cT3N2M0 and clinical Stage ⅢA. After induction chemoradiotherapy(weekly CBDCA plus PTX[5 courses]and concurrent radiation of 50 Gy, left upper lobectomy with lymph node dissection(ND2a-1)was performed. The postoperative pathological findings were large cell carcinoma, ypT2aN2M0, Stage ⅢA, with complete resection; the PD-L1 tumor proportion score was 50 to 74%. Consolidation chemotherapy( triweekly CBDCA plus PTX, 1 course)followed. Twelve months after surgery, he developed mediastinal lymph node recurrence(#4L), and pembrolizumab was administered every 3 weeks as a first-line treatment. Complete response was evident after 3 courses; thus, we continued this monotherapy. After 35 courses(24 months)of pembrolizumab, we discontinued the regimen. Twenty-two months later, the disease has not progressed. The patient is being followed-up in our outpatient department. We report a case of recurrent postoperative lung cancer with continuous tumor shrinkage after discontinuation of pembrolizumab.

Uniportal thoracoscopic pulmonary segmentectomy provides good perioperative results and early postoperative recovery

Background

Methods

Results

Conclusions

Infrared thoracoscopic pulmonary segmentectomy with intravenous indocyanine green administration using preoperative simulation

Infrared thoracoscopy with intravenous indocyanine green administration is one of the useful methods to identify an appropriate intersegmental line during thoracoscopic pulmonary segmentectomy. In this procedure, we have introduced preoperative simulation to calculate the distance between the target tumour and intersegmental plane using Ziostation2 (Ziosoft, Tokyo, Japan) to ensure sufficient surgical margin without palpation. By using this preoperative simulation, we obtained sufficient surgical margin in a patient with a 16-mm part-solid nodular shadow undergoing infrared thoracoscopic upper division (S1-3) segmentectomy of left upper lobe with intravenous indocyanine green administration. The discrepancy between the virtual and the actual surgical margin was <10 mm. This preoperative simulation can help us obtain sufficient surgical margin without palpation of the tumour in infrared thoracoscopic segmentectomy.

Uniportal thoracoscopic lateral and posterior (S9+10) segmentectomy using a modified intersegmental tunneling procedure

The lateral and posterior basal (S9+10) segmentectomy is one of the most challenging operations because it requires exposure and recognition of pulmonary vessel branches and bronchi that are located deep in the lung parenchyma. To perform this difficult operation appropriately, even via a uniportal approach, we adopted a modified version of the intersegmental tunneling procedure. Intersegmental tunneling followed by division of the intersegmental plane between S6 and S9-10 was performed before the division of the A9+10 in the modified version. In addition to the clear recognition of the dominant vessels and bronchi permitted by the tunneling procedure, we were able to divide them smoothly using a stapler in the modified version, although the tip of the inserted stapler stuck to the lung parenchyma in the previous version. This method might be universally preferable, even for less experienced surgeons, when they perform this challenging operation.

Uniportal thoracoscopic anterior and lingular (S3+4+5) segmentectomy of the left upper lobe using intravenous indocyanine green

Although an anterior and lingular (S3+4+5) segmentectomy of the left upper lobe is rarely performed, this type of segmentectomy is very useful to ensure a sufficient margin when the tumor is located at the border between the anterior segment (S3) and the superior lingular segment (S4). However, it might be technically difficult to perform this unusual segmentectomy via a uniportal approach because of the limited angulation and exposure of the peripheral vessels/bronchi. We present the successful results of a patient undergoing uniportal thoracoscopic S3+4+5 segmentectomy of the left upper lobe and describe some technical details.

Uniportal thoracoscopic apical (S1) segmentectomy of the right upper lobe via an anterior approach

An apical (S1) segmentectomy of the right upper lobe is considered one of the most challenging procedures among the uncommon pulmonary segmentectomies. However, we consider that the uniportal thoracoscopic approach, for which the single port access is located at the 4th intercostal space of the anterior axillary line, makes this challenging operation easier because we can recognize any intrathoracic vessels and bronchi that should be divided just under the incision. Moreover, it is easy to insert a stapler to divide an intersegmental plane between S1 and the other segments because of the good surgical view provided by this approach. In this video tutorial, we describe the successful results of a patient undergoing uniportal thoracoscopic S1 segmentectomy of the right lower lobe and explain the nuances of performing it.

Comprehensive expressional analysis of chemosensitivity-related markers in large cell neuroendocrine carcinoma of the lung

Objectives

Various drug‐sensitivity markers have been reported to be associated with tumor progression and chemotherapy resistance. Detailed expression profiles of sensitivity markers for cytotoxic chemotherapy in pulmonary large cell neuroendocrine carcinoma (LCNEC) remain unclear. Herein, we aimed to clarify the correlation between the expression of drug‐sensitivity markers and clinicopathological features, prognostic impact, and status of tumor immunity in patients with LCNEC.

Methods

We retrospectively analyzed the correlation between clinicopathological features and the expression of drug‐sensitivity‐related markers, including vascular endothelial growth factor 2 (VEGFR2), thymidylate synthase (TS), tubulin beta 3 class III (TUBB3), topoisomerase I (Topo‐I), and Topo‐II in 92 surgically resected LCNEC samples. Furthermore, we examined the prognostic significance of expression of these and their correlation with the immune cell status.

Results

Overall, high expression of TS, TUBB3, VEGFR2, Topo‐I, and Topo‐II was detected in 50 (54%), 31 (34%), 23 (25%), 65 (71%), and 36 (39%) samples, respectively. Univariate and multivariate analyses revealed that advanced pathological T and N factors, positive lymphatic permeation, and Topo‐II expression were independent unfavorable prognosticators for recurrence‐free survival, and advanced pathological T and N factors, Topo‐II positive expression, and TS positive expression were independent unfavorable prognosticators for overall survival. In terms of correlation with immune cell status, higher expression of VEGFR2 was closely linked to negative PD‐L1 expression.

Conclusions

These findings suggest that elevated Topo‐II and TS expression may contribute to poor outcomes through protumoral biology in patients with LCNEC, and elevated VEGFR2 expression might negatively impact tumor immune reactions in LCNEC.

The learning curve of thoracoscopic surgery in a single surgeon and successful implementation of uniportal approach

Background

In some institutions, a recently introduced uniportal approach has replaced the multiportal approach for thoracoscopic major pulmonary resection. This study investigated the effect of this change on the surgical learning curve by examining the perioperative results of a single surgeon.

Methods

Between April 2012 and August 2020, 376 patients with primary lung cancer underwent thoracoscopic lobectomy with ND2a-1/2 lymphadenectomy in the authors’ hospital. Surgery was performed by one of the authors in 189 of these patients, who were thus enrolled in this retrospective study. The surgeries were classified chronologically into five phases and the operative time, rate of intraoperative massive bleeding, and rate of postoperative prolonged air leak (PAL) were then compared. The learning curve (i.e., operative time) was assessed by Spearman’s rank correlation test. The perioperative results achieved with the uniportal and multiportal approaches were also compared before and after the patients were matched for their characteristics based on the propensity score.

Results

The five phases differed significantly with respect to the operative time and rate of postoperative PAL (P<0.0001, P=0.0061). The correlation between operative time and number of consecutive cases was also significant (r=−0.579, P<0.0001). Superior results in terms of operative time (P<0.0001), duration of postoperative drainage (P<0.0001), and rate of postoperative PAL (P=0.0034) were obtained using a uniportal rather than multiportal approach.

Conclusions

The transition from a multiportal to a uniportal approach did not cause a decline in the learning curve of thoracoscopic lobectomy with ND2a-1/2 lymphadenectomy.

[Alectinib for an Octogenarian Patient with Poor Performance Status and ALK Fusion Gene-Positive Lung Cancer-A Case Report]

An 89-year-old female who had been clinically diagnosed with primary lung cancer underwent right upper lobectomy and lymph node dissection(ND2a-2). Postoperative pathological staging revealed a stage ⅡA(pT1bN1M0)adenocarcinoma that was negative for an EGFR mutation. Nineteen months after surgery, the patient developed a mediastinal lymph node metastasis, and radiotherapy was prescribed. Thirty-eight months later, she developed new mediastinal/hilar lymph node metastases and was prescribed pemetrexed(500 mg on day 1 of each of 3 weeks)as the first-line therapy. A complete response was evident after 10 courses. However, she developed grade 3 nausea, and pemetrexed was discontinued. During 10 months of follow-up, no new lesion appeared; therefore, follow-up was discontinued. Ninety-three months after surgery, she was referred to our hospital because an abnormal shadow was apparent on chest roentgenography. A thorough examination revealed pleural dissemination, pulmonary metastases, mediastinal/hilar lymph node metastases, an adrenal metastasis, and bone metastases. Although her performance status(PS)was poor(grade 4), as the diagnosis was ALK fusion gene-positive adenocarcinoma, alectinib(600 mg once daily)was commenced as the second-line therapy. Complete response was achieved 14 months later(ie, 108 months after surgery and 89 months after postoperative recurrence). Thus, an octogenarian patient with poor PS and ALK fusion gene-positive adenocarcinoma exhibited a complete response after treatment with alectinib.

[Video-assisted Thoracoscopic Total Pleural Adhesiolysis:Tips and Pitfalls]

PURPOSES

Here, we present the tips and pitfalls of video-assisted thoracoscopic( VATS) total pleural adhesiolysis( TPA), determined on an empirical basis.

PATIENTS AND METHODS

From 2012 to 2020, VATS-TPA was performed in 33 patients undergoing pulmonary anatomic lung resection at our institute. The basic procedure was as follows:after peeling off the area of pleural adhesion surrounding the surgical ports using the fingers, the thoracoscope was inserted into the thorax and the adhesions in other areas were peeled off under thoracoscopic guidance.

RESULTS

The adhesiolysis group had a longer operating time, greater blood loss, and higher rate of conversion to thoracotomy compared to the non-adhesiolysis group. However, the results were acceptable considering the extra manipulation for adhesiolysis.

CONCLUSIONS

VATS-TPA is a necessary component of the standard surgical procedure for general thoracic surgeons in cases of total pleural adhesion.

A prospective comparative study of thoracoscopic transareolar and uniportal approaches for young male patients with primary spontaneous pneumothorax

OBJECTIVE

In this study, we introduce a novel approach, thoracoscopic transareolar bullectomy, for treating young male patients with primary spontaneous pneumothorax (PSP). This approach might be less invasive and cosmetically superior to existing methods. We also prospectively compared transareolar and uniportal approaches.

METHODS

Between April 2018 and July 2019, 40 patients were prospectively assigned to transareolar (n = 21) and uniportal (n = 19) groups. We compared patient characteristics and perioperative results. Approximately 1 week or 1 year after the operation, postoperative pain was evaluated using a numerical rating scale (NRS), and cosmetic satisfaction was graded on a four-point scale.

RESULTS

We found no significant between-group differences in patient characteristics or perioperative results. NRS scores did not differ on postoperative day (POD) 7 (transareolar, 1.8 ± 0.9 vs. uniportal, 1.6 ± 0.9; p = 0.62) or in postoperative month (POM) 12 (transareolar, 1.3 ± 0.5 vs. uniportal, 1.1 ± 0.5; p = 0.18). In terms of cosmetic satisfaction, the transareolar group was more satisfied on POD 7 (transareolar, 3.5 ± 0.6 vs. uniportal, 2.9 ± 0.9; p = 0.02) and in POM 12 (transareolar, 3.8 ± 0.5 vs. uniportal, 3.3 ± 0.9; p = 0.0065).

CONCLUSION

Although the perioperative results of the transareolar and uniportal approaches were similar, the former approach afforded a little better cosmetic satisfaction and might be useful option for young males with PSP.

[Lung Cancer Cases with Spontaneous Regression]

Case 1 was a 79-year-old man. Computed tomography (CT) showed a nodule in the left upper lobe. Surgery was planned, but the regression of the nodule was noted and the surgery was postponed. Six months later, the nodule shadow increased again, and was surgically resected. Pathological diagnosis was adenocarcinoma. Case 2 was an 82-year-old man. CT showed a nodule in the right lower lobe and surgery was planned, but the nodule regressed. Three months later, it increased and was resected. It was pathological diagnosed as squamous cell carcinoma. Although spontaneous regression of lung cancer is rare, careful follow up of the regressed nodules shadow is required because of possible regrowth after the regression.

[Erlotinib plus Bevacizumab Therapy for Postoperative Recurrence of Adenosquamous Cell Carcinoma Harboring EGFR Mutation-A Case Report]

A 59-year-old man clinically diagnosed with primary lung cancer underwent left lower lobectomy and lymph node dissection( ND2a-2). The postoperative pathological stage was ⅠB(pT2aN0M0), and the lesion was positive for epidermal growth factor receptor(EGFR)exon 21 L858R mutation. Thirty months after surgery, the patient developed pleural dissemination and effusion in the left pleural cavity. Carboplatin(AUC=6, day 1, every 3 weeks)and nab-paclitaxel(100 mg/m2, day 1 and day 8, every 3 weeks)were administered as first-line therapy. Progressive disease was evident 10 months after 4 courses of first-line therapy. Pembrolizumab(200 mg, day 1, every 3 weeks)was then administered as second-line therapy. After 7 months(9 courses of therapy), the lung cancer had metastasized to the left third intercostal muscle, and the pleural nodules regrew. The former lesion was treated with radiotherapy owing to the development of pain in the chest. Erlotinib (150 mg once daily)and bevacizumab(15 mg/kg, day 1, every 3 weeks)were initiated as third-line therapy, resulting in complete response at 14 months(67 months after surgery, 37 months after postoperative recurrence). The prognosis of patients with EGFR-positive pulmonary adenosquamous carcinoma and undergoing treatment with EGFR-tyrosine kinase inhibitors(TKI)is reportedly poor. Herein, we report a rare case of adenosquamous carcinoma with EGFR mutation presenting complete response following treatment with EGFR-TKI.

[Postoperative Recurrence of ROS1‒Positive Pulmonary Adenocarcinoma after 19 Years]

A 73‒year‒old woman underwent right lower lobectomy for Stage ⅠA(pathological Stage T1N0M0)pulmonary adenocarcinoma. After 19 years, she complained of dyspnea on exertion. Computed tomography revealed metastatic lesions in the bilateral supraclavicular, mediastinal, and hilar lymph nodes. Thoracoscopic lymph node biopsy showed recurrence of the adenocarcinoma, and immunohistochemical staining confirmed that the metastases were ROS1‒positive. The patient responded well to crizotinib therapy. The prognosis of non‒small‒cell lung cancer is considered favorable when it does not recur within 5 years, postoperation. However, few studies have reported the recurrence of ROS1‒positive pulmonary adenocarcinoma after a long disease‒free interval. Long‒term postoperative follow‒up is essential for patients with ROS1‒positive pulmonary adenocarcinomas.

Safety and feasibility of uniportal video-assisted thoracoscopic uncommon segmentectomy

Background

In recent years, opportunities to conduct anatomical segmentectomies for early stage lung cancer, metastatic lung tumor, and so on have been increasing. Generally, uniportal video-assisted thoracoscopic surgery (U-VATS) uncommon segmentectomy is technically more complicated because of limited angulation compared to multiportal VATS (M-VATS) and the need to treat peripheral vessels/bronchi compared to common segmentectomy. This study aimed to determine the safety and feasibility of U-VATS uncommon segmentectomy compared with U-VATS common segmentectomy and M-VATS uncommon segmentectomy.

Methods

We retrospectively reviewed the medical records of 76 patients in the M-VATS group and 45 patients in the U-VATS group who underwent VATS segmentectomy from January 2015 to December 2020. During that period, the perioperative results of U-VATS uncommon (n=22) segmentectomy were compared with those of U-VATS common (n=23) and M-VATS uncommon (n=37) segmentectomy. Uncommon segmentectomy was defined as any segmentectomy other than segmentectomies of the lingual, basilar, or superior segment of the lower lobe (S6), and upper division of the left upper lobe. All patients in our department underwent preoperative three-dimensional computed tomography (3D-CT) angiography and bronchography to image bronchovascular structures and determine the resection line.

Results

Patients characteristics were similar between the U-VATS uncommon segmentectomy group and the U-VATS common segmentectomy group or the M-VATS uncommon segmentectomy group. In U-VATS, there were no significant differences between common and uncommon segmentectomy in operation time, postoperative drainage, postoperative hospitalization, and postoperative complications. Comparing M-VATS and U-VATS uncommon segmentectomies, operation time (145±35 vs. 185±44 min, P<0.001) and postoperative hospitalization (3.1±1.6 vs. 4.2±1.8 days, P=0.02) were significantly shorter in the U-VATS group than in the M-VATS group. There were no significant differences in blood loss, intraoperative bleeding, duration of postoperative drainage and postoperative complications.

Conclusions

In U-VATS, both types of segmentectomies can be achieved with similar results. Moreover, U-VATS shortened operation time and postoperative hospitalization in uncommon segmentectomy compared with conventional M-VATS. U-VATS is a useful approach for uncommon segmentectomy.