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Objectives Prolonged air leak after pulmonary resection strongly influences chest tube duration and hospitalization. This prospective study aimed to report a series of experiences with a synthetic sealant (TissuePatch™) and compare them with a combination covering method (polyglycolic acid sheet + fibrin glue) for air leaks after pulmonary surgery. Methods We included 51 patients (age: 20–89 years) who underwent lung resection. Patients who presented with alveolar air leak during the intraoperative water sealing test were randomly assigned to the TissuePatch™ or combination covering method groups. The chest tube was removed when there was no air leak over a period of 6 h, and no active bleeding under continuous monitoring using a digital drainage system. The chest tube duration was assessed, and various perioperative factors (such as the index of prolonged air leak score) were evaluated. Results Twenty (39.2%) patients developed intraoperative air leak; ten patients received TissuePatch™; and one patient who was receiving TissuePatch™ switched to the combination covering method because of broken TissuePatch™. The chest tube duration, index of prolonged air leak score, prolonged air leak, other complications, and postoperative hospitalization in both groups were similar. No TissuePatch™-related adverse events were reported. Conclusions Results from the use of TissuePatch™ were almost similar to those associated with the use of combination covering method in preventing prolonged postoperative air leak after pulmonary resection. Randomized, double-arm studies are required to confirm the efficacy of TissuePatch™ observed during this study.

Objectives A clear understanding of energy devices would help achieve high effectiveness and safety and guide the selection of devices. The present review aimed to elucidate the efficacy and adverse events of energy devices in lung cancer to guide the selection of appropriate devices depending on the situation. Methods Four major databases were searched electronically for relevant articles published until 16 April 2021. The reference lists of the identified papers were examined. We excluded (1) irrelevant studies, (2) manuscripts published in languages other than English and Japanese, (3) duplicates, and (4) studies for which the full text was not available in the databases. The results and key information obtained were summarized by means of a narrative approach. Results A total of 78 papers were included in the review and these were categorized according to the main topic of investigation as follows: (1) electrosurgery-related injuries, (2) fundamentals of electrosurgery, (3) monopolar devices, (4) bipolar electrosurgical devices, (5) ultrasonic energy devices, (6) energy devices in lung cancer surgery, (7) operating room fire risks, and (8) basic principles of surgery. Conclusions Understanding energy devices could help us use them in a more effective and safer manner. Knowledge of their selection criteria (suitability), merits, risks, and safety precautions relevant to each process of lung cancer surgery could guide appropriate selection.

The water submersion test (W-test) has the risk of overlooking air leaks during lung resection. We assessed the relationship between alveolar air leakage and intrathoracic gas concentrations as a novel intraoperative air leak detection method. We compared the W-test results with intrathoracic gas concentrations of desflurane, oxygen (O2), and carbon dioxide (CO2), prospectively measured using a gas analyser built-in into the anaesthesia machine before and after lung resection. Eighty-eight patients were included; 32 patients had a positive W-test, 31 of whom had elevated levels of all three gases. Eight of the 56 W-test negative patients had elevated levels of all three gases and were positive in a reconfirmation W-test. After repair, 27/31 patients demonstrated negative W-tests, but two patients with elevated levels of all three gases concentrations had postoperative air leaks. When intrathoracic O2 concentration increased, all patients showed an air leak. Conversely, no air leak was detected when intrathoracic concentrations without O2 were measured. We found a positive correlation (correlation coefficients: desflurane, r = 0.84; O2, r = 0.80; CO2. r = 0.77) between the number of bubbles observed in the W-test and gas concentrations. Intrathoracic gas concentration measurements could be a useful alternative or complementary method to the W-test for detecting intraoperative alveolar air leaks. Given that high concentration O2 is frequently use for reinflate the collapsed lungs, intrathoracic O2 measurement could be the most effective way to detect alveolar leakage.

The purpose of this study was to investigate the associated factors of insulation failure (IF) in reusable endoscopic instruments. The insulation coating of reusable endoscopic instruments underwent routine visual checks, hand washing to remove visible stains, and mechanized sterilization. We recorded the cleaning number and usage period of all instruments. The instruments were tested for IF using a detector. IF was found in eight of 69 devices (11.6%). Examining by clinical specialty, we found IF in 4 of 28 gastrointestinal (14.3%), 3 of 20 gynecological (15.0%), 1 of 12 urological (8.3%), and none of the nine thoracic devices. The median distance from the tip to the damaged part was 5 cm (3–5 cm). In the IF and the intact groups, the period of use [7 years (6–8) versus 7 years (4–8), P = 0.90] and the number of cleanings [281 (261–323) versus 261 (179–320), P = 0.27] were not significantly different. The IF group included products of three different companies; however, six of the eight (75.0%) were from the same company. Cleaning methods and usage period have a lower impact on IF. The use of reusable forceps as a monopolar device was found to pose a higher risk, requiring regular assessments.

Pyridine (py) and ammonia (NH 3 ) have been widely used as raw materials in manufacturing processes; however, both are volatile, and their vapor is detrimental to human health. To limit the exposure of those who work with py and NH 3 vapor, the development of effective techniques to sense atmospheric levels of py and NH 3 in order to decrease their concentration when required is important. In the present study, we found that crystals of bis(benzimidazole)NiCl 2 ( 1 , bis(benzimidazole) = phenylbis(benzimidazol-2-yl)methane)) adsorb py and NH 3 vapor with a concomitant color change from purple to green (py) or light purple (NH 3 ). Powder X-ray diffraction, UV–Vis diffuse reflectance, and IR spectroscopic studies revealed that these color changes are induced by the formation of trans- [NiCl 2 (py) 4 ] ( 2 ) or [Ni(NH 3 ) 6 ]Cl 2 ( 3 ). A time-dependent analysis of the py-vapor adsorption indicated that the formation of 2 from 1 proceeds non-uniformly in the solid. Crystals of 1 were furthermore found to adsorb py or NH 3 even at low concentrations (py: ~ 6 ppm; NH 3 : ~ 33 ppm), albeit that a color change was not observed in these cases. Graphical abstract

Purpose To develop deep learning models using thoracoscopic images to identify visceral pleural invasion (VPI) in patients with clinical stage I lung adenocarcinoma, and to verify if these models can be applied clinically. Methods Two deep learning models, one based on a convolutional neural network (CNN) and the other based on a vision transformer (ViT), were applied and trained via 463 images (VPI negative: 269 images, VPI positive: 194 images) captured from surgical videos of 81 patients. Model performances were validated via an independent test dataset containing 46 images (VPI negative: 28 images, VPI positive: 18 images) from 46 test patients. Results The areas under the receiver operating characteristic curves of the CNN-based and ViT-based models were 0.77 and 0.84 ( p  = 0.304), respectively. The accuracy, sensitivity, specificity, and positive and negative predictive values were 73.91, 83.33, 67.86, 62.50, and 86.36% for the CNN-based model and 78.26, 77.78, 78.57, 70.00, and 84.62% for the ViT-based model, respectively. These models’ diagnostic abilities were comparable to those of board-certified thoracic surgeons and tended to be superior to those of non-board-certified thoracic surgeons. Conclusion The deep learning model systems can be utilized in clinical applications via data expansion.

INTRODUCTION: Lung cancer with chest wall (CW) involvement can develop metastases directly to the ipsilateral axillary lymph node (ALN) via lymphatic flow of the CW. Such metastatic ALNs should be evaluated as locoregional metastases, and multimodal treatment of patients with stage III lung cancer including surgery may be utilized.CASE PRESENTATION: A 59-year-old man presented with a chief complaint of back pain and was diagnosed as having primary lung adenocarcinoma of the right upper lobe with CW involvement and an ipsilateral ALN metastasis (cT3N0M1b: IVA, 8th edition of the tumor, node, metastasis). We found no mediastinal lymph node (MLN) metastases, so we believed that the metastatic ALN involved metastasis directly from the primary lesion via lymphatic flow of the CW. Therefore, radical surgery after neoadjuvant chemoradiotherapy was chosen as the treatment. During the operation, we performed a right upper lobectomy combined with resection of the involved CW through a posterolateral incision. The right upper limb was then raised, and the scapula was displaced backward, which allowed us to dissect the right ALN.CONCLUSIONS: Because complete resection can be achieved through intraoperative repositioning of the upper limb, surgical treatment may be utilized for patients with locally advanced lung cancer who have CW involvement and ipsilateral ALN metastasis when the ipsilateral ALN metastasis is believed to have developed from the involved CW rather than from the MLN.

INTRODUCTION: A staple line granuloma (SG) in the lung, which arises adjacent to a staple line after lung surgery, is often difficult to differentiate from a stump recurrence. We report two cases of lung tumors that were suspected of being SGs, and the tumors resolved after the use of oral tranilast.CASE PRESENTATION: Case 1 is a 71-year-old woman who underwent a right S8 segmentectomy for lung adenocarcinoma (pT1miN0M0, stage IA1). A follow-up chest computed tomography (CT) scan, which was performed 9 months after surgery, revealed a mass adjacent to the staple line. The lesion disappeared by the 3rd month after administration of tranilast with no recurrence. Case 2 is a 70-year-old woman who underwent wedge resection for metastatic lung cancer originating from renal cancer. A follow-up chest CT scan, which we obtained 8 months after surgery, revealed a nodule adjacent to the staple line. The lesion disappeared by the 4th month after administration of tranilast with no recurrence.CONCLUSIONS: Administration of tranilast can be a safe and effective diagnostic treatment for SG, when the treatment is performed with strict imaging follow-up and histologic biopsy in mind.

Background/objectives: This study aimed to investigate the impact of single-inhaler triple therapy on selecting treatment for lung cancer and the perioperative period in lung cancer patients with chronic obstructive pulmonary disease (COPD) and a forced expiratory volume in 1 s (FEV1) <1.5 L. Methods: All patients had baseline FEV1 < 1.5 L. The therapeutic drug for COPD, fluticasone furoate/umeclidinium/vilanterol, was initiated 2 weeks preoperatively and continued until 3 months postoperatively. Radical surgery was actively recommended for patients with an FEV1 ≥ 1.5 L after COPD treatment; otherwise, palliative surgery and postoperative complication risks were discussed. Results: Among 675 lung cancer patients, 214 (31.7%) had COPD, 41 of whom with FEV1 < 1.5 L were enrolled. After triple-inhaler therapy, FEV1 improved to ≥1.5 L in 63.4% of patients. Significant differences in the Brinkman index (840 vs. 1120, p = 0.0058) and radical resection (88.5% vs. 40.0%, p = 0.0030) were observed between patients with FEV1 ≥ 1.5 L and <1.5 L post-treatment. Pneumonia and home oxygen therapy occurred in two cases (4.9%) and one case (2.4%), respectively, all of which were patients with FEV1 < 1.5 L post-treatment. Among patients undergoing anatomical lung resection, triple-inhaler therapy significantly improved not only post-inhalation FEV1 (1.26 vs. 1.55 L, p < 0.0001), but also FEV1 at 3 months postoperatively compared to the value before inhalation (1.31 vs. 1.26 L, p = 0.042). Conclusions: Preoperative triple therapy in lung cancer patients with untreated COPD and FEV1 < 1.5 L improved respiratory function and increased the feasibility of performing radical resection surgery. Furthermore, it was considered safe and effective, indicating the potential to maintain preoperative respiratory function without increasing perioperative complications.

Immunoglobulin G4‐related disease (IgG4‐RD) is a newly recognized disease, and therefore its clinical features are not yet fully understood. Here, we describe a surgical case of metachronous bilateral IgG4‐related pleuritis and postoperative chylothorax. This case could provide key insights into the pathology of IgG4‐RD from a surgical perspective. We present a 70‐year‐old woman who had a right pleural mass. Video‐assisted thoracoscopic pleural mass resection was performed, and the patient was diagnosed with right‐sided IgG4‐related pleuritis. Two years later, she was also diagnosed with left‐sided IgG4‐related pleuritis. We suspected the presence of IgG4‐positive plasma cell infiltration. Additionally, she experienced a complicated postoperative chylothorax on the left side. It is important to consider the altered course of lymphatic vessels when extensively removing the pleura near the right thoracic duct. The occurrence of metachronous bilateral IgG4‐associated pleuritis has not been previously reported, making this case particularly significant for understanding the pathology of IgG4‐RD from a surgical standpoint. Here, we describe a case of metachronous bilateral IgG4‐related pleuritis. We suspected IgG4‐positive plasma cell infiltration from the right to left side, based on both the imaging and pathological findings. The patient also had a complicated postoperative chylothorax on the left side. Although IgG4‐RD is systemic, no metachronous bilateral IgG4‐associated pleuritis has surprisingly been reported; thus, this case could be key to understanding the pathology of IgG4‐RD from a surgical viewpoint. We also review previous reports on the cause of metachronous bilateral pleuritis and postoperative chylothorax.