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Background: The characteristics and prognostic impacts of early graft infiltration after lung transplantation and clinically diagnosed acute rejection remain unclear. Furthermore, the alloimmune response status in lung transplantation remains uninvestigated., Methods: In this retrospective cohort study, we evaluated 92 living-donor lobar lung transplantations (LDLLT) to establish the effect of graft infiltration-diagnosed as acute rejection-within one-month post-transplantation (cAR), on chronic lung allograft dysfunction (CLAD)-free LDLLT survival. The alloimmune response was evaluated using the carboxyfluorescein diacetate succinimidyl ester (CFSE)-mixed lymphocyte reaction (MLR) in lymphocytes isolated from donor and recipient blood one week after LDLLT. The anti-donor proliferation of CD4+ and CD8+ T cells was determined using flow cytometry., Results: cAR was observed in 54 (58.7 %) patients who underwent LDLLT. The median postoperative day of cAR occurrence was 7 days (ranging between 5 and 28 days). Only one episode of cAR occurred in 51 patients (94.4 %). CLAD-free survival was significantly lower in patients who underwent cAR, especially within 2 years after LDLLT (p = 0.016). Thirteen CFSE-MLR assays were performed in seven consecutive LDLLT cases (six bilateral and one unilateral LDLLT). Increased anti-donor proliferation of CD8+ T cells, but not CD4+ T cells, was associated with cAR, irrespective of human leukocyte antigen (HLA) class I mismatch., Conclusion: Early lung graft infiltration after LDLLT increases the risk of the early development of CALD. Augmented anti-donor CD8 + response was also associated with graft infiltration, which could not be predicted from HLA mismatches but could be monitored using MLR in LDLLT., Competing Interests: Declaration of competing interest The authors of this manuscript have no competing interest to disclose., (Copyright © 2025 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: To validate the clinical impacts of the prognostic nutritional index (PNI), an immune-nutritional blood marker, in patients with resectable non-small cell lung cancer (NSCLC) using multicenter cohort data., Methods: The subjects of this retrospective multicenter study, involving 11 hospitals, were patients who underwent curative lung resection for pathological stage IA-IIIA NSCLC. We analyzed the relationship between the preoperative PNI and postoperative outcomes. Patients were divided into a high PNI group and a low PNI group (cutoff: 45). We also performed exact matching and three propensity score-based methods to validate the results., Results: Among the total 2,770 patients, 2,272 (82.0%) had a high PNI (>45) and 498 (18.0%) had a low PNI (≤45). A low preoperative PNI was a predictor of increased overall postoperative complications (relative risk 1.49; 95% confidence interval (CI) 1.31-1.69) and an independent adverse prognostic factor for overall survival (hazard ratio 1.77; 95% CI 1.45-2.17) and recurrence-free survival (1.34; 95% CI 1.14-1.59). All the methods we used (whole cohort, exact matching, and three propensity score methods) showed consistent results., Conclusions: The findings of this multicenter study suggest that immune-nutritional assessment using the PNI will provide useful prognostic information for patients with resectable NSCLC., Competing Interests: Declarations. Conflict of interest: We have no conflicts of interest in relation to this work, nor did we receive any funding., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Gauzoma is a foreign body reactive granuloma which is an extremely rare complication of thoracic surgery. We describe a case of a Gauzoma in which the gauzes were removed by mini-thoracotomy as a less invasive procedure, discovered incidentally after 35 years of follow-up., Case Presentation: A 51-year-old man was referred to our department for hyperhidrosis treatment, and imaging studies and biopsy confirmed the diagnosis of Gauzoma. As the Gauzoma gradually grew for a few years, surgical intervention was judged necessary, and the removal of the gauzes was performed in this case. A two-stage operation in two days was required to complete the surgery. The completion of gauze removal was confirmed in the second surgery using a postoperative computed tomography (CT) scan. The patient is currently doing well 17 months after surgery, and the size of granuloma unchanged., Conclusion: We performed the removal of the gauzes as the treatment for Gauzoma. Although removing the gauze may have prevented its growth so far, careful follow-up is still needed., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: We obtained written consent from the patient for the publication of this case report and any accompanying images. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Objectives: Generally, HLA matching between donors and recipients is not performed in lung transplantation (LTx). Therefore, whether HLA mismatch between donors and recipients (D/R mismatch) influences postoperative outcomes after LTx remains uncertain. In this study, we investigated the influence of D/R mismatch on postoperative outcomes after cadaveric LTx (CLT)., Methods: A total of 140 CLT procedures were performed between 2012 and 2020. After excluding 5 recipients with preformed DSA and 1 recipient undergoing re-LTx, 134 recipients were enrolled in this retrospective study. The postoperative outcomes were compared between recipients with higher and lower D/R mismatches., Results: The median D/R mismatch (A/B/DR loci) was 4.0 (range, 1-6). When dividing these 134 recipients into two groups (H group [D/R mismatch ≥ 5, n = 57] and L group [D/R mismatch ≤ 4, n = 77]), there were no significant differences in the patient backgrounds. The lengths of hospital and intensive care unit stays were similar (p = 0.215 and p = 0.37, respectively). Although the overall survival was not significantly better in the H group than in the L group (p = 0.062), chronic lung allograft dysfunction-free survival was significantly better in the H group than in the L group (p = 0.027). Conversely, there was no significant difference in the cumulative incidence of de novo donor-specific anti-HLA antibodies (dnDSAs) between the two groups (p = 0.716)., Conclusions: No significant difference in dnDSA development was observed between patients with higher and lower D/R HLA mismatches. Given the favorable outcomes in the high HLA mismatch group, CLTs can be performed safely in recipients with high D/R HLA mismatches., Competing Interests: Declarations. Conflict of interest: None., (© 2024. The Author(s).)

Objectives: This study was designed to examine the outcomes of adult living-donor lobar lung transplants (LDLLTs) using small-for-size grafts., Methods: A calculated graft forced vital capacity of <50% of the predicted forced vital capacity of the recipient was considered to indicate a small-for-size graft. Adult recipients (≥18 years) who underwent LDLLTs between 2008 and 2022 were included in this study., Results: We performed 80 adult LDLLTs, using small-for-size grafts in 15 patients and non-small grafts in 65 patients. Grade 3 primary graft dysfunction developed within 72 h after the transplant in 3 patients (20%) in the small group and in 3 patients (4.6%) in the non-small group (P = 0.0763). The 1- and 5-year survival rates were 86.7% and 69.3% in the small group and 93.8% and 77.1% in the non-small group (P = 0.742). In the small group, the native lungs were spared in 8 patients, whereas 2 lobar grafts were implanted with non-spared native lungs in the other 7 patients. The 1- and 5-year survival rates were significantly better in the spared group (both 100%) than in the non-spared group (71.4% and 23.8%; P = 0.0375). The spared group showed a significantly higher median percent forced vital capacity after the transplant than the non-spared group (68.5% vs 44.9%; P = 0.0027)., Conclusions: Although the use of small-for-size grafts was associated with a higher rate of severe primary graft dysfunction, no differences were found in survival rates. When the graft is small, the native lung should be partially spared if possible., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Surgical resection followed by adjuvant chemotherapy is currently the first choice for the treatment of clinical N1 (cN1) non-small cell lung cancer (NSCLC). However, diagnosing cN1 correctly can be difficult, even with current imaging diagnostic technologies. We aimed to analyze the diagnostic accuracy of preoperative nodal status and the predictive factors for nodal upstaging of cN1-NSCLC., Methods: Patients receiving surgery for cN1-NSCLC in 2010 (n = 1040) were enrolled in the Japanese Joint Committee of Lung Cancer Registry Database. We investigated the diagnostic accuracy of cN1, predictive factors for nodal upstaging, and prognostic factors for overall survival (OS) and recurrence-free survival (RFS)., Results: The 5-year OS and RFS for all patients were 58.2% and 42.7%, respectively. The postoperative pathological nodal status included N0 (36.6%), N1 (39.7%), N2 (23.6%), and N3 (0.1%). In multivariate analysis, younger age (P = .005), no history of smoking (P = .006), and adenocarcinoma (P < .001) were significant predictive factors for nodal upstaging. Older age (P < .001) and higher clinical T (cT) factor (P < .001) were significant indicators for worse OS, while older age (P = .02), higher cT factor (P = .019), high carcinoembryonic antigen value (P = .002), and adenocarcinoma (P = .008) were significant indicators for worse RFS., Conclusions: The diagnostic accuracy of cN1 in this study was ~40%. No history of smoking and adenocarcinoma were significant predictors for nodal upstaging. Although younger age was a significant predictor for nodal upstaging, it was a significant factor for better prognosis., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To explore the characteristics and prognostic impact of chronic lung allograft dysfunction (CLAD) after deceased-donor lung transplantation and living-donor lobar lung transplantation, wherein the lower lobes from 2 donors are usually transplanted into one recipient., Methods: The clinical data of 123 deceased-donor and 67 living-donor lung transplantations performed in adult patients at our institution between June 2008 and September 2019 were retrospectively reviewed. The cumulative incidence of CLAD was evaluated on a per-recipient and per-donor graft basis using the Kaplan-Meier method., Results: A smaller number of human leukocyte antigen mismatches, shorter ischemic time, and lower incidence of grade 3 primary graft dysfunction were observed in living-donor transplantation than in deceased-donor transplantation (P < .001). Restrictive allograft syndrome-type CLAD occurred in 9 (20.9%) of 43 patients with CLAD after deceased-donor transplantation and 9 (45.0%) of 20 patients with CLAD after living-donor transplantation. CLAD occurred unilaterally in 15 patients (75.0%) after bilateral living-donor transplantation. Despite the greater incidence of restrictive allograft syndrome-type CLAD after living-donor transplantation, the overall survival rates after the transplantation and survival rates after the onset of CLAD were comparable between the patients receiving deceased-donor transplants and living-donor transplants. The cumulative incidence of CLAD per recipient was similar between recipients of deceased-donor and the living-donor transplants (P = .32). In the per-donor graft analysis, the cumulative incidence of CLAD was significantly lower in the living-donor grafts than in the deceased-donor grafts (P = .003)., Conclusions: The manifestation of CLAD after living-donor lobar lung transplantation is unique and differs from that after deceased-donor lung transplantation., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Penetrating cardiac injuries are usually fatal and associated with poor survival rates., Case Presentation: A 69-year-old man was injured in a motor vehicle accident and suffered from left hemothorax and multiple rib fractures near the heart. A comprehensive assessment raised suspicions of lacerated pericardium and myocardial injury. Consequently, a thoracoscopy was performed 9 h after injury. A penetrating cardiac injury was detected and surgically treated via video-assisted thoracoscopic surgery. The patient recovered uneventfully and was discharged on postoperative day 16., Conclusion: Exploratory video-assisted thoracoscopic surgery may play a key role in the primary diagnosis of patients with high-energy chest traumas with cardiac injury and simultaneously allow for the appropriate surgical interventions., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Authors. Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.)

Background: It has been recently recognized that pulmonary cyst may develop after pulmonary resection, causing various symptoms. Most previously reported cases were after upper lobectomy in patients with chronic obstructive lung disease (COPD)., Case Presentation: Case 1 was a man in his 70 s with interstitial pneumonia (IP). Right lower lobectomy was performed for metastatic lung tumor using video-assisted thoracoscopic surgery (VATS). On postoperative day (POD) 19, computed tomography (CT) revealed a large cyst at the upper interlobular surface of the middle lobe, with pneumoderma and pneumomediastinum. The cyst was incised, polyglycolic acid (PGA) sheet and fibrin glue were applied, and the cyst was sutured. The sutured line was covered again with PGA sheet and fibrin glue. Case 2 was a man in his 70 s with COPD. Right upper lobectomy for primary lung cancer was performed using VATS. On POD 17, CT revealed a large pulmonary cyst at the apex of S6 and massive air leakage was observed. The same surgical procedure as that used in case 1 was performed. Cases 3 and 4 were healthy donors for living-donor lung transplantation. Two months after the right lower lobectomy in Case 3 and 3 months after the left lower lobectomy in Case 4, the patients had respiratory symptoms such as dyspnea and hemosputum. CT revealed a large cyst on the diaphragmatic surface of the right middle lobe in Case 3 and on the posterior mediastinal surface of the left upper lobe in Case 4. Cyst incision, soft coagulation, and application of PGA sheet with fibrin glue were performed in both cases. CT performed 1 year after surgery showed no development of a pulmonary cyst or air space in these four cases., Conclusions: Pulmonary cysts newly formed after lobectomy can develop not only in COPD or IP but also in healthy lungs. Our findings suggest that incision of the cyst and application of fibrin glue and PGA sheet with or without suturing the cyst wall is effective for management., (© 2024. The Author(s).)

Background: We have shown the efficacy of CD26/dipeptidyl peptidase 4 (CD26/DPP-4) inhibitors, antidiabetic agents, in allograft protection after experimental lung transplantation (LTx). We aimed to elucidate whether CD26/DPP-4 inhibitors effectively improve postoperative outcomes after clinical LTx., Methods: We retrospectively reviewed the records of patients undergoing LTx at our institution between 2010 and 2021 and extracted records of patients with diabetes mellitus (DM) at 6 months post-LTx. The patient characteristics and postoperative outcomes were analyzed. We established 6 months post-LTx as the landmark point for predicting overall survival (OS) and chronic lung allograft dysfunction (CLAD)-free survival. Hazard ratios were estimated by Cox regression after propensity score weighting, using CD26/DPP-4 inhibitor treatment up to 6 months post-LTx as the exposure variable. We evaluated CLAD samples pathologically, including for CD26/DPP-4 immunohistochemistry., Results: Of 102 LTx patients with DM, 29 and 73 were treated with and without CD26/DPP-4 inhibitors, respectively. Based on propensity score adjustment using standardized mortality ratio weighting, the 5-year OS rates were 77.0% and 44.3%, and the 5-year CLAD-free survival rates 77.8% and 49.1%, in patients treated with and without CD26/DPP-4 inhibitors, respectively. The hazard ratio for CD26/DPP-4 inhibitor use was 0.34 (95% confidence interval (CI) 0.14-0.82, p = 0.017) for OS and 0.47 (95% CI 0.22-1.01, p = 0.054) for CLAD-free survival. We detected CD26/DPP-4 expression in the CLAD grafts of patients without CD26/DPP-4 inhibitors., Conclusions: Analysis using propensity score weighting showed that CD26/DPP-4 inhibitors positively affected the postoperative prognosis of LTx patients with DM., (Copyright © 2023 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

ABO-incompatible (ABO-I) living-donor lobar lung transplantation (LDLLT) was successfully performed in a 14-year-old girl who suffered from bronchiolitis obliterans due to graft-versus-host disease following hematopoietic stem cell transplantation. In the ABO-I LDLLT procedure, the blood type O patient received a right lower lobe donated from her blood type B father and a left lower lobe donated from her blood type O mother. Desensitization therapy, using rituximab, immunosuppressants, and plasmapheresis, was implemented for 3 weeks prior to transplantation to reduce the production of anti-B antibodies in the recipient and prevent acute antibody-mediated rejection after ABO-I LDLLT., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Shabih Manzar reports was provided by LSU Health Shreveport., (Copyright © 2023 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The effect of human leukocyte antigen mismatches between donors and recipients on postoperative outcomes of lung transplantation remains controversial. We retrospectively reviewed adult recipients receiving living-donor lobar lung transplantation (LDLLT) to examine the difference in de novo donor-specific antibody (dnDSA) development and clinically diagnosed unilateral chronic lung allograft dysfunction per graft (unilateral CLAD) between lung grafts donated by spouses (nonblood relatives) and nonspouses (relatives within the third degree). We also investigated the difference in prognoses between recipients undergoing LDLLTs including spouse donors (spousal LDLLTs) and not including spouse donors (nonspousal LDLLTs)., Methods: In this study, 63 adult recipients undergoing LDLLTs (61 bilateral and 2 unilateral LDLLTs from 124 living donors) between 2008 and 2020 were enrolled. The cumulative incidence of dnDSAs per lung graft was calculated, and prognoses were compared between recipients undergoing spousal and nonspousal LDLLTs., Results: The cumulative incidence of both dnDSAs and unilateral CLAD in grafts donated by spouses was significantly higher than that in grafts donated by nonspouses (5-y incidence of dnDSAs: 18.7% versus 6.4%, P = 0.038; 5-y incidence of unilateral CLAD: 45.6% versus 19.4%, P = 0.011). However, there were no significant differences in the overall survival or chronic lung allograft dysfunction-free survival between recipients undergoing spousal and nonspousal LDLLTs ( P > 0.99 and P = 0.434, respectively)., Conclusions: Although there were no significant differences in prognoses between spousal and nonspousal LDLLTs, more attention should be paid to spousal LDLLTs because of the higher development rate of dnDSAs and unilateral CLAD., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Poor health-related quality of life (HRQL) at the registration for lung transplantation is related to waitlist mortality. We investigated the relationship between 1-year change in HRQL and subsequent outcomes in patients waitlisted for lung transplantation., Methods: In a 5-year longitudinal study, we analyzed the factors related to waitlist mortality in 197 lung transplant patients registered on the Japan Organ Transplant Network. HRQL was assessed using St. George's Respiratory Questionnaire (SGRQ), and factors related to changes in SGRQ scores were evaluated after 1 year. We assessed the relationship between the 1-year change in SGRQ score and subsequent mortality or hospitalization., Results: Among 197 patients, 108 remained waitlisted during the first-year assessment. During the median follow-up period of 469 d, 28 patients died, and 54 underwent lung transplantation. Univariate Cox proportional hazards analysis revealed that the changes in all components and total score of the SGRQ after 1 year were associated with waitlist mortality (p < 0.05). Stepwise multivariate analysis revealed that the 1-year changes in SGRQ scores were significantly related to waitlist mortality. Forty-three patients with worsened HRQL after 1 year had higher likelihoods of hospitalization (p = 0.038) and mortality (p = 0.026) after 1 and 4 years of follow-up, respectively, than 61 patients without worsened HRQL., Conclusions: Patients with worsened health status during the first year after registration had higher likelihoods of hospitalization and mortality after 1 and 4 years of follow-up, respectively, than those without worsened HRQL. Strategies to improve health status while waiting are needed to reduce waitlist hospitalization or mortality., Competing Interests: Conflict of Interest The authors have no conflicts of interest., (Copyright © 2023 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Background: Living-donor lobar lung transplantation (LDLLT) remains a life-saving option for pediatric patients with respiratory failure. However, the long-term survival and post-transplant quality of adult lobar grafts transplanted into children are unknown. Therefore, this study aimed to evaluate the outcomes of pediatric LDLLT and post-transplant graft growth., Methods: We retrospectively reviewed the prospectively collected clinical data of 25 living-donor lung transplantations performed in 24 pediatric recipients aged ≤17 years. The annual pulmonary function test data and computed tomography scans of 12 recipients, followed up for >5 years without significant complications, were used to evaluate growth in height, graft function, and radiological changes. The Kaplan-Meier method and simple linear regression were performed for analysis., Results: Bilateral lower lobe transplantation was performed in 12 patients, unilateral lower lobe transplantation in 12, and bilateral middle lobe transplantation in 1. The median volumetric size matching at transplantation was 142% (range, 54%-457%). The 5- and 10-year overall survival rates were 87.7% and 75.1༅, respectively. Chronic lung allograft dysfunction occurred in 2 patients. During a median follow-up of 6 years, the median increases in height and vital capacity were 14.4% (range, 0.80%-43.5%) and 58.5% (range, 6.7%-322%), respectively. Graft weight was positively correlated with graft volume (r 2 =0.622, p<0.001) after the graft volume exceeded the original lobar volume in the donor., Conclusions: This study shows that pediatric LDLLT offers satisfactory long-term survival, with the growth of mature adult lobes transplanted into growing children., (Copyright © 2022 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Living-donor lobar lung transplantation (LDLLT) is a life-saving procedure for critically ill patients with various lung diseases, including pulmonary hypertension (PH). However, there are concerns regarding the development of heart failure with pulmonary oedema after LDLLT in which only 1 or 2 lobes are implanted. This study aimed to compare the preoperative conditions and postoperative outcomes of LDLLT with those of cadaveric lung transplantation (CLT) in PH patients., Methods: Between 2008 and 2021, 34 lung transplants for PH, including 12 LDLLTs (5 single and 7 bilateral) and 22 bilateral CLTs, were performed. Preoperative variables and postoperative outcomes were retrospectively compared between the 2 procedures., Results: Based on the preoperative variables of less ambulatory ability (41.7% vs 100%, P < 0.001), a higher proportion of World Health Organization class 4 (83.3% vs 18.2%, P < 0.001) and higher mean pulmonary artery pressure (74.4 vs 57.3 mmHg, P = 0.040), LDLLT patients were more debilitated than CLT patients. Nevertheless, hospital death was similar between the 2 groups (8.3% vs 9.1%, P > 0.99, respectively). Furthermore, the 5-year overall survival rate was similar between the 2 groups (90.0% vs 76.3%, P = 0.489)., Conclusions: Although LDLLT patients with PH had worse preoperative conditions and received smaller grafts than CLT patients, LDLLT patients demonstrated similar perioperative outcomes and prognoses as CLT patients. LDLLT is a viable treatment option for patients with PH., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: The effect of postoperative tegafur-uracil on overall survival (OS) after resection of stage I adenocarcinoma has been shown in clinical trials. The purpose of this study was to investigate whether findings from randomized trials of adjuvant tegafur-uracil are reproducible in a real-world setting., Methods: A retrospective cohort study was performed using a multi-institutional database that included all patients who underwent complete resection of pathological stage I adenocarcinoma between 2014 and 2016. Survival outcomes for patients managed with and without tegafur-uracil were analyzed using the Kaplan-Meier method and a Cox proportional hazards model for the whole patient cohort and in a selected cohort based on eligibility criteria of a previous randomized trial. Propensity score matching was used to adjust for confounding effects., Results: After propensity score matching, the hazard ratios for OS were 0.57 (95% confidence interval (CI) 0.29-1.14, P = 0.11) in the whole cohort and 0.69 (95% CI 0.32-1.50, P = 0.35) in the selected cohort., Conclusions: The effects of tegafur-uracil in this retrospective study appear to be consistent with those found in randomized clinical trials. These effects may be maximized in patients aged from 45 to 75 years., (© 2022. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Objectives: We developed a novel wireless localization technique after electromagnetic navigation bronchoscopy-guided radiofrequency identification marker placement for fluoroscopically invisible small lung lesions. We conducted an observational study to investigate the feasibility of this technique and retrospectively compared 2 marking approaches with or without cone-beam computed tomography (CBCT)., Methods: Consecutive patients from January 2021 to March 2022 in our institution were enrolled. Markers were placed central to the lesions either in a bronchoscopic suite under intravenous anaesthesia or a hybrid operation theatre with CBCT under general anaesthesia. The efficacy of the 2 marking methods was compared using an inverse probability of treatment weighting adjusted analysis., Results: Totally 80 markers were placed (45 under CBCT and 35 under fluoroscopy) for 74 patients with 80 lesions [mean size: 6.9 mm (interquartile range: 5.1-8.4) at a median depth from the pleura of 14.0 mm (interquartile range: 8.5-19.5)]. The median distance from marker to lesion was 9.1 mm, with a pleural depth of 15.5 mm. The tumour resection rate was 97.5% (78/80) with the median surgical margin of 10.0 mm (interquartile range: 8.0-11.0). Although the bronchoscopy time was longer using CBCT because of the need for 2.8 scans per lesion, the distance from the marker to the lesion was shorter for marking using CBCT than marking using fluoroscopy (adjusted difference: -4.56, 95% confidence interval: -6.51 to -2.61, P < 0.001)., Conclusions: Electromagnetic navigation bronchoscopy-guided radiofrequency identification marking provided a high tumour resection rate with sufficient surgical margins., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to analyse the long-term survival outcomes and prognostic factors of patients receiving epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) as first-line treatment for postoperative recurrent EGFR-mutated lung adenocarcinoma., Methods: Using a multi-institutional database, we performed a retrospective chart review to identify all patients who had undergone complete resection of stage I-III EGFR-mutated lung adenocarcinoma at 11 acute care hospitals between 2009 and 2016 and had received first-line EGFR-TKI treatment for postoperative recurrence. Adverse events, progression-free survival (PFS) and overall survival (OS) were investigated. Survival outcomes were assessed using Kaplan-Meier analysis. Cox proportional hazards models were used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for PFS and OS., Results: The study sample comprised 154 patients with a median age of 69. The total numbers of events were 101 for PFS and 60 for OS. The median PFS and OS were 26.1 and 55.4 months, respectively. In the multivariable analysis, EGFR ex 21 L858R mutation (HR: 1.71, 95% CI: 1.15-2.55) and shorter disease-free intervals (HR: 0.98, 95% CI: 0.96-0.99) were significantly associated with shorter PFS. Age (HR: 1.03, 95% CI: 1.00-1.07), smoking history (HR: 2.31, 95% CI: 1.35-3.94) and pathological N2 disease at the initial surgery (HR: 2.30, 95% CI: 1.32-4.00) were significantly associated with shorter OS., Conclusions: First-line EGFR-TKI treatment was generally associated with favourable survival outcomes in patients with postoperative recurrent EGFR-mutated lung adenocarcinoma. EGFR ex 21 L858R mutation may be an important prognostic factor for shorter PFS., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Adjuvant cisplatin‑vinorelbine is a standard therapy for stage II/III lung cancer. However, a poor survival rate of patients with lung cancer is attributed to vinorelbine resistance arising from ATP‑binding cassette (ABC) sub‑family B member 1 (ABCB1) and phosphorylated Fyn (p‑Fyn) overexpression. However, the underlying mechanisms remain unclear. NF‑E2‑related factor 2 (Nrf2) regulates the ABC family and activates the nuclear transport of Fyn. The present study evaluated the roles of the Nrf2/p‑Fyn/ABCB1 axis in vinorelbine‑resistant (VR) cells and clinical samples. To establish VR cells, H1299 cells were exposed to vinorelbine, and the intracellular reactive oxygen species (ROS) level in the H1299 cells was determined using a DCFH‑DA assay. The total and subcellular expression of Nrf2, ABCB1 and p‑Fyn in VR cells was evaluated. Immunofluorescence was used to detect the subcellular localization of p‑Fyn in VR cells. A cell viability assay was used to examine whether the sensitivity of VR cells to vinorelbine is dependent on Nrf2 activity. Immunohistochemistry was performed on 104 tissue samples from patients with lung cancer who underwent surgery followed by cisplatin‑vinorelbine treatment. The results revealed that persistent exposure to vinorelbine induced intracellular ROS formation in H1299 cells. p‑Fyn was localized in the nucleus, and ABCB1 and Nrf2 were overexpressed in VR cells. ABCB1 expression was dependent on Nrf2 downstream activation. The decreased expression of Nrf2 restored the sensitivity of VR cells to vinorelbine. In the surgical samples, Nrf2 and ABCB1 were associated with disease‑free survival, and p‑Fyn was associated with overall survival (P<0.05). On the whole, the present study demonstrates that Nrf2 upregulates ABCB1 and, accompanied by the nuclear accumulation of p‑Fyn, induces vinorelbine resistance. These findings may facilitate the development of drug resistance prevention strategies or new drug targets against non‑small cell lung cancer.

Lung parenchyma-sparing bronchial resection is uncommon, and the operative procedure depends on the cause and location of the stenosis. We present 6 cases and discuss the different surgical strategies for sleeve resection of the central airway without lung resection. Bronchoplasty for the main bronchus and truncus intermedius was performed with a posterolateral approach. We resected the right main bronchus including the right lateral wall of the lower trachea and half of the carina obliquely and performed an anastomosis. The tumour in the left lobar bronchus was exposed and removed by transient division of the accompanying pulmonary artery. Although post-transplant stenosis and malacia can pose a challenge, bronchoplasty can be used as a definitive treatment in experienced centres., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Identifying the risks for chronic lung allograft dysfunction (CLAD) after lung transplantation (LTx) is beneficial to the patient. We hypothesized that diabetes mellitus (DM) is relevant to CLAD development. Our study aimed to clarify if DM is a risk for poor post-LTx outcomes., Methods: The records of patients first undergoing LTx in our institution between 2010 and 2018 were reviewed retrospectively. Patient characteristics and postoperative outcomes were analysed. We established 6 months post-LTx as the landmark point for predicting overall survival (OS) and CLAD development. To identify perioperative DM, we evaluated the patient for DM at 6 months post-LTx., Results: A total of 172 patients were investigated. DM and CLAD occurred in 76 and 39 patients, respectively, and 40 died. At 6 months post-LTx, the unadjusted and adjusted hazard ratios of DM for OS were 3.36 [95% confidence interval (CI) = 1.67-6.73] and 2.78 (95% CI = 1.35-5.75), respectively. The unadjusted and adjusted hazard ratios of DM for CLAD-free survival were 2.20 (95% CI = 1.27-3.80) and 2.15 (95% CI = 1.24-3.74). The patients with DM were older and had a higher body mass index and more incidents of post-LTx malignant disease than the non-DM patients. The 5-year OS and CLAD-free survival rates of the patients with or without DM were 57.2% vs 86.5% and 50.1% vs 72.9%, respectively., Conclusions: Perioperative DM was identified as an independent adverse factor for OS and CLAD-free survival. Perioperative management of DM should be emphasized in the clinical setting of LTx., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Lung ischemia-reperfusion injury (IRI) is a form of acute lung injury characterized by nonspecific alveolar damage and lung edema due to robust inflammation. Little is known about the roles of specialized proresolving lipid mediators (SPMs) in lung IRI. Therefore, we aimed to evaluate the dynamic changes in endogenous SPMs during the initiation and resolution of lung IRI and to determine the effects of SPM supplementation on lung IRI., Methods: We used a rat left hilar clamp model with 90 min of ischemia, followed by reperfusion. Dynamic changes in endogenous SPMs were evaluated using liquid chromatography-tandem mass spectrometry., Results: Endogenous SPMs in the left lung showed a decreasing trend after 1 h of reperfusion. Oxygenation improved between 3 and 7 d following reperfusion; however, the level of endogenous SPMs remained low compared with that in the naïve lung. Among SPM receptors, only formyl peptide receptor type 2 (ALX/FPR2) gene expression in the left lung was increased 3 h after reperfusion, and the inflammatory cells were immunohistochemically positive for ALX/FPR2. Administration of aspirin-triggered (AT) resolvin D1 (AT-RvD1) and AT lipoxin A4 (AT-LXA4), which are agonistic to ALX/FPR2, immediately after reperfusion improved lung function, reduced inflammatory cytokine levels, attenuated lung edema, and decreased neutrophil infiltration 3 h after reperfusion. The effects of AT-RvD1 and AT-LXA4 were not observed after pretreatment with the ALX/FPR2 antagonist., Conclusions: The level of intrapulmonary endogenous SPMs decreased during lung IRI process and the administration of AT-RvD1 and AT-LXA4 prevented the exacerbation of lung injury via ALX/FPR2., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Part-solid lung adenocarcinoma appears as a heterogeneous subgroup, and its surgical management is controversial. This study aimed to elucidate whether preoperative carcinoembryonic antigen, a time-honored tumor marker, can be used as a prognostic factor that contributes to its management., Methods: We retrospectively reviewed consecutive patients with clinical-T1a-cN0M0 part-solid adenocarcinoma who underwent surgical resection between January 2011 and December 2015 at two institutions., Results: Overall, 288 patients were identified. The median age was 69 years with 176 patients (61%) being female. The median follow-up time was 5.6 years. Lymph node metastases were found in 6 (15%) of 41 patients with elevated carcinoembryonic antigen levels, while 10 (4.0%) of 247 patients had normal carcinoembryonic antigen levels ( P  = 0.016). The 5-year overall survival rates in patients with normal and elevated carcinoembryonic antigen levels were 96.9% and 87.2%, respectively ( P  = 0.006), and the 5-year relapse-free survival rates were 91.8% and 62.8%, respectively ( P  < 0.001). The multivariable analysis revealed that preoperative carcinoembryonic antigen level was a significant prognostic factor for relapse-free survival (hazard ratio [HR] = 2.92, 95% confidence interval [CI] = 1.63-5.25, P  < 0.001). Among the patients with elevated carcinoembryonic antigen levels, the 5-year overall survival rates in those undergoing lobar resection and segmentectomy were 87.0% and 88.9%, respectively ( P  = 0.59), and the 5-year relapse-free survival rates were 61.7% and 66.7%, respectively ( P  = 0.84)., Conclusions: Our data suggest that preoperative carcinoembryonic antigen level appears to be an important predictor of postoperative survival outcomes in early-stage part-solid adenocarcinoma. Further studies are required to optimize management of patients with elevated preoperative carcinoembryonic antigen levels, although segmentectomy appeared acceptable in those patients.

Background: In Japan, a unique medical consultant system for donor evaluation and management has been developed in an effort to maximize the use of extended criteria donor lungs. The aim of this study was to investigate the impact of donor pneumonia (DP) on the outcome after lung transplantation under this system., Materials and Methods: Clinical data of 85 patients who underwent deceased donor lung transplantation (41 single and 44 bilateral lung transplants) between August 2012 and March 2018 were reviewed. DP was defined as the recognition of pneumonia on imaging with positive bacterial culture in the airway at the time of transplantation., Results: Twenty-three transplanted lung grafts were recognized as having DP (27.1%). Serial chest x-rays at the donor hospital did not show deteriorating infiltration or consolidation. The PaO 2 /FiO 2 ratio at brain death evaluations were similar between the donor pneumonia (DP) negative (-) and donor pneumonia (DP) positive (+) groups. Perioperative antibiotics were effective against 94% of isolated bacteria. The duration of postoperative antibiotics therapy was longer in the DP (+) group (P = .02). The incidence of primary graft dysfunction and acute rejection, intensive care unit stay, chronic lung allograft dysfunction-free survival, and overall survival were similar between the DP (+) and DP (-) groups., Conclusions: Transplantation of donor lung grafts harboring pneumonia but having a similar oxygenation level to those without pneumonia was safely performed and did not affect long-term outcome. Appropriate evaluation of serial imaging at donor hospital and suitable perioperative antibiotic management may be reasons for this outcome., (Copyright © 2022 Elsevier Inc. All rights reserved.)

We report our successful experience in two lung transplant cases in which ex vivo lung perfusion (EVLP) was used to evaluate the function of injured brain-dead donor lungs that were otherwise initially unacceptable. After the donor's lungs were declined for transplantation by all other transplant centers, the lungs were offered to the patients listed for lung transplantation in our hospital. The donor lung function was considered acceptable for transplantation after the 3-h EVLP assessment. In the first case, a 32-year-old man with bronchiolitis obliterans after hematopoietic stem cell transplantation underwent hybrid lung transplantation, that was right brain-dead donor lung transplantation, combined with native-upper lobe sparing living-donor lobar lung transplantation on the left side. In the second case, a 61-year-old woman received the right single lung transplantation for idiopathic pulmonary fibrosis. Both patients are doing well at one and a half years after lung transplantation., (© 2022. The Author(s), under exclusive licence to The Japanese Association for Thoracic Surgery.)

This study aimed to analyze the influences of single nucleotide polymorphisms (SNPs) in Fc gamma receptor IIA (FCGR2A) on postoperative outcomes after lung transplantation (LTx). We enrolled 191 lung transplant recipients [80 undergoing living-donor lobar lung transplants (LDLLTs) and 111 undergoing deceased-donor lung transplants (DDLTs)] in this study. We identified SNPs in FCGR2A (131 histidine [H] or arginine [R]; rs1801274) and reviewed the infectious complication-free survival after ICU discharge. The SNPs in FCGR2A comprised H/H (n = 53), H/R (n = 24), and R/R (n = 3) in LDLLT and H/H (n = 67), H/R (n = 42), and R/R (n = 2) in DDLT. Recipients with H/H (H/H group) and those with H/R or R/R (R group) were compared in the analyses of infectious complications. In multivariate analyses, the R group of SNPs in FCGR2A was associated with pneumonia-free survival {HR: 2.52 [95% confidence interval (CI): 1.35-4.71], P = 0.004}, fungal infection-free survival [HR: 2.50 (95% CI: 1.07-5.84), P = 0.035], and cytomegalovirus infection-free survival [HR: 2.24 (95% CI: 1.07-4.69), P = 0.032] in LDLLT, but it was not associated with infectious complication-free survival in DDLT. Therefore, in LDLLT, more attention to infectious complications might need to be paid for LTx recipients with H/R or R/R than for those with H/H., (© 2021 Steunstichting ESOT. Published by John Wiley & Sons Ltd.)

Background: Despite growing interest in donor-specific antibodies (DSAs) and antibody-mediated rejection (AMR) in lung transplantation (LTx), no study evaluating the outcomes in recipients with de novo DSAs (dnDSAs) in living-donor lobar LTx (LDLLT) exists. We compared various characteristics of DSAs in LDLLT with those in cadaveric LTx (CLT) based on prospectively collected data., Methods: Between October 2009 and September 2019, 211 recipients underwent LTx (128 CLTs and 83 LDLLTs). We reviewed 108 CLTs and 74 LDLLTs to determine the characteristics and clinical impact of dnDSAs. Eighteen data-deficient cases, 7 cases with preformed DSAs, and 4 re-transplants were excluded., Results: There were significant differences between CLT and LDLLT patients in age, primary disease, ischemic time, and number of human leukocyte antigen mismatches per donor. The dnDSA incidence in LDLLT (6.8%) was significantly lower than that in CLT (19.4%, p = 0.02). The dnDSAs appeared later in LDLLT (mean 1,256 days) than in CLT (mean 196 days, p = 0.003). According to Cox models analyzed using dnDSA as a time-dependent covariate, dnDSA positivity was significantly associated with a poor overall survival (OS; hazard ratio [HR] 3.46, 95% confidence interval [CI] 1.59-7.57, p = 0.002) and poor CLAD-free survival in case of CLT (HR: 2.23, 95% CI: 1.08-4.63, p = 0.003). However, no such significant associations were noted in case of LDLLT., Conclusions: The dnDSA occurrence was significantly lower and later in LDLLT than in CLT. Furthermore, dnDSA-positivity was significantly associated with worse OS and CLAD-free survival after CLT but not after LDLLT., Competing Interests: Conflicts of interest The authors have no conflicts of interest or funding to disclose., (Copyright © 2021 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Few studies have evaluated the outcomes of lung transplantation (LTx) in recipients with preformed donor-specific antibodies (DSAs). This study investigated the postoperative changes in preformed DSAs based on prospectively collected data of DSAs, and the influences of preformed DSAs on postoperative outcomes among LTx recipients., Methods: Between July 2010 and December 2019, 216 recipients underwent LTx (81 living-donor lobar lung transplants and 135 deceased-donor lung transplants). We reviewed 8 cases with preformed DSAs to determine postoperative changes in DSAs and compared postoperative outcomes between recipients with and without DSAs., Results: The preoperative mean fluorescence intensity of preformed DSAs ranged from 1141 to 14 695. Two recipients experienced antibody-mediated rejection within 2 weeks after LTx. DSAs disappeared in 7 recipients; however, 1 recipient experienced the relapse of DSAs and died from chronic lung allograft syndrome (CLAD), whereas 1 recipient had persisting DSAs within the study period and died from CLAD. Neither overall survival (OS) nor CLAD-free survival was significantly different between recipients with and without DSAs (P = 0.26 and P = 0.17, respectively). However, both OS and CLAD-free survival were significantly lower in recipients with DSAs against HLA class II than in those without these antibodies {5-year OS: 25.0% [95% confidence interval (CI): 0.9-66.5%] vs 72.1% (95% CI: 63.8-78.9%), P = 0.030 and 5-year CLAD-free survival: 26.7% (95% CI: 1.0-68.6%) vs 73.7% (95% CI: 66.5-79.5%), P = 0.002}., Conclusions: Prognosis in recipients experiencing the relapse of preformed DSAs and those with persisting DSAs may be poor. The recipients with anti-HLA class II preformed DSAs had a significantly worse prognosis., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Molecular hydrogen (H 2 ) has protective effects against ischemia-reperfusion injury in various organs. Because they are easier to transport and safer to use than inhaled H 2 , H 2 -rich solutions are suitable for organ preservation. In this study, we examined the protective effects of an H 2 -rich solution for lung preservation in a canine left lung transplantation (LTx) model., Methods: Ten beagles underwent orthotopic left LTx after 23 hours of cold ischemia followed by reperfusion for 4 hours. Forty-five minutes after reperfusion, the right main pulmonary artery was clamped to evaluate the function of the implanted graft. The beagles were divided into two groups: control group (n = 5), and H 2 group (n = 5). In the control group, the donor lungs were flushed and immersed during cold preservation at 4°C using ET-Kyoto solution, and in the H 2 group, these were flushed and immersed using H 2 -rich ET-Kyoto solution. Physiologic assessments were performed during reperfusion. After reperfusion, the wet-to-dry ratios were determined, and histology examinations were performed., Results: Significantly higher partial pressure of arterial oxygen and significantly lower partial pressure of carbon dioxide were observed in the H 2 group than in the control group (P = .045 and P < .001, respectively). The wet-to-dry ratio was significantly lower in the H 2 group than in the control group (P = .032). Moreover, in histology examination, less lung injury and fewer apoptotic cells were observed in the H 2 group (P < .001 and P < .001, respectively)., Conclusions: Our results demonstrated that the H 2 -rich preservation solution attenuated ischemia-reperfusion injury in a canine left LTx model., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: We investigated the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) to evaluate programmed cell death ligand-1 (PD-L1) expression in patients with advanced non-small cell lung cancer (NSCLC)., Methods: A retrospective chart review of patients who underwent EBUS-TBNA between April 2017 and April 2019 was conducted. Among patients diagnosed with NSCLC, we investigated the rate of successful evaluation of tumor PD-L1 expression, compared the relevant factors between patients with evaluable and those with unevaluable PD-L1 expression, and examined the response to immune checkpoint inhibitors (ICIs) after EBUS-TBNA., Results: Of the 40 patients assessed, 32 (80%) had evaluable PD-L1 expression. Patients with evaluable PD-L1 expression were older than those with unevaluable PD-L1 expression (p = 0.017), and we noted a tendency for a larger diameter of the biopsied lymph node (p = 0.12). The response rate to ICIs was 100% in patients with a tumor proportion score (TPS) ≥ 50%, 33% in those with a TPS 1-49%, and 0% in those with a TPS < 1%., Conclusion: The diagnostic yield of EBUS-TBNA to evaluate PD-L1 expression in advanced NSCLC appeared acceptable in association with relevant clinical outcomes after treatment with ICIs. A further prospective study with a larger sample size is required to confirm our findings.

Background: Molecular hydrogen can reduce the oxidative stress of ischemia-reperfusion injury in various organs for transplantation and potentially improve survival rates in recipients. This study aimed to evaluate the protective effects of a hydrogen-rich preservation solution against ischemia-reperfusion injury after cold ischemia in rat lung transplantation., Methods: Lewis rats were divided into a nontransplant group (n = 3), minimum-ischemia group (n = 3), cold ischemia group (n = 6), and cold ischemia with hydrogen-rich (more than 1.0 ppm) preservation solution group (n = 6). The rats in the nontransplant group underwent simple thoracotomy, and the rats in the remaining 3 groups underwent orthotopic left lung transplantation. The ischemic time was <30 minutes in the minimum-ischemia group and 6 hours in the cold ischemia groups. After 2-hour reperfusion, we evaluated arterial blood gas levels, pulmonary function, lung wet-to-dry weight ratio, and histologic features of the lung tissue. The expression of proinflammatory cytokines was measured using quantitative polymerase chain reaction assays, and 8-hydroxydeoxyguanosine levels were evaluated using enzyme-linked immunosorbent assays., Results: When compared with the nontransplant and minimum-ischemia groups, the cold ischemia group had lower dynamic compliance, lower oxygenation levels, and higher wet-to-dry weight ratios. However, these variables were significantly improved in the cold ischemia with hydrogen-rich preservation solution group. This group also had fewer signs of perivascular edema, lower interleukin-1β messenger RNA expression, and lower 8-hydroxydeoxyguanosine levels than the cold ischemia group., Conclusions: The use of a hydrogen-rich preservation solution attenuates ischemia-reperfusion injury in rat lungs during cold ischemia through antioxidant and anti-inflammatory effects., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: The pulmonary artery (PA) in patients with pulmonary hypertension (PH) becomes dilated. We analyzed the postoperative changes of the main PA after lung transplantation (LuTx)., Methods: The subjects of this retrospective study were 68 LuTx recipients, divided into a PH group (n = 36) and a non-PH group (n = 32), based on preoperative right heart catheterization findings. The PA diameter was measured on chest computed tomography. We evaluated the correlation between the mean pulmonary arterial pressure (mPAP) and the main PA diameter and compared the main PA diameters before and 3 months after LuTx., Results: The main PA diameter was significantly correlated with the mPAP (r = 0.423, P < 0.001). Preoperatively, the mean main PA diameter in the PH group was significantly greater than that in the non-PH group. However, by 3 months after LuTx, the main PA diameter in the PH group had decreased significantly from 32.4 ± 6.7 to 26.9 ± 4.8 mm (P < 0.001), while that in the non-PH group had decreased minimally from 28.3 ± 4.9 to 26.4 ± 4.6 mm (P < 0.001), resulting in no significant difference in postoperative main PA diameters between the two groups., Conclusions: The main PA diameter in recipients with PH was enlarged and correlated with the mPAP. The dilated main PA diameter in PH patients decreased shortly after LuTx.

Backgrounds: The number of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) cases is increasing due to its less-invasiveness and usefulness. However, there are several unresolved issues, including the existence of incomplete cases and complications. This study aimed to investigate the frequency and diagnostic management of incomplete EBUS-TBNA cases., Methods: Between July 2009 and December 2017, 424 patients underwent EBUS-TBNA for the diagnosis of suspected malignancy. Among them, we retrospectively reviewed the frequency, characteristics and diagnostic managements of incomplete cases of EBUS-TBNA., Results: EBUS-TBNA was not completed in 16 patients (3.8%), all of whom underwent EBUS-TBNA cases under conscious sedation. The factors for incompleteness of EBUS-TBNA under conscious sedation were divided into two groups: impossibility to perform EBUS-TBNA under conscious sedation (n=8) and impossibility to perform safe needle biopsy (n=8). The former factor consisted of strong coughing reflex and insufficient sedation (n=5), frequent desaturation during EBUS-TBNA (n=2), and allergy to lidocaine (n=1), while the latter factor consisted of anatomical reasons (n=4), abundant blood flow in the target lesion (n=3), and invisibility of the target lesion due to airway deformation (n=1). Eventually, 10 out of 16 cases were histologically diagnosed as having malignancy by a surgical approach (n=5) and EBUS-TBNA under general anesthesia (n=5)., Conclusions: Although the number was small, we did note some incomplete cases of EBUS-TBNA under conscious sedation. In incomplete cases under conscious sedation, EBUS-TBNA under general anesthesia and other surgical approaches can be considered as additional options., Competing Interests: Conflicts of Interest: M Hamaji and TF Chen-Yoshikawa serve as the unpaid editorial board members of Journal of Thoracic Disease from Oct 2018 to Sep 2020 and from Apr 2019 to Mar 2021 respectively. The other authors have no conflicts of interest to declare., (2020 Journal of Thoracic Disease. All rights reserved.)

Scimitar syndrome is a rare congenital anomaly in which the right lung is hypoplastic and a scimitar vein is draining into the inferior vena cava. It is known to be sometimes complicated with pulmonary sequestration. However, a right single pulmonary vein draining normally into the left atrium is rare. Here, we report a case of variant scimitar syndrome complicated by intralobar pulmonary sequestration containing an adenocarcinoma. In this case, the aberrant arteries from the abdominal aorta were ligated and the pulmonary sequestration containing adenocarcinoma was completely removed through wedge resection. Twenty months after the surgery, the patient was alive without cancer recurrence. An elaborate preoperative plan is important for safety in cases with vascular malformation.

Objectives: In a living-donor lobectomy, the donor undergoes a right or left lower lobectomy. The surgical procedures for living-donor lobectomy are sometimes influenced by the anatomical variations of the pulmonary vein (PV). The goal of this study was to analyse the PV variations in living donors and to review the influence of these variations on the surgical procedures used., Methods: Between June 2008 and September 2018, 154 living donors underwent right or left lower lobectomy. The PV variations were analysed using 3-dimensional computed tomography (3D-CT), and the surgical management of these variations was reviewed., Results: Among 154 donors, 21 PV variations that could influence the surgical procedure for a right lower lobectomy were found in 19 (12.3%) donors, whereas no such variations for a left lower lobectomy were found. Detected PV variations were dorsal branch of the right upper PV (n = 12), middle PV draining into the right lower PV (n = 6) and the superior segment branch of the right lower PV draining into the right upper PV (n = 3). Among 96 donors undergoing right lower lobectomy, 9 (9.4%) donors had PV variations that could influence the surgical procedure. In 2 donors, sparing of PV branches with multiple vascular clamps was required. Pulmonary venoplasty was not required in any donor, whereas pulmonary venoplasty in recipient surgery was required in 4 recipients. There were no complications related to the surgical procedures performed on the PV., Conclusions: Living-donor lobectomy was performed safely owing to the preoperative evaluation of PV on 3D-CT and the use of appropriate surgical approaches to PV., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: In standard bilateral living-donor lobar lung transplantation (LDLLT), the right and left lower lobes from 2 healthy donors are implanted in the recipient in place of whole right and left lungs. In other words, total 10 lobes (5 lobes in each donor) are shared by the 2 donors (4 lobes in each donor) and the recipient (2 lobes) in this transplant procedure. This study aimed to compare pulmonary function between donors and recipients before and after LDLLT., Methods: We performed 76 LDLLT procedures between June 2008 and March 2017. After excluding 12 single LDLLT and 11 native-lung-sparing LDLLT procedures, we identified 38 recipients of bilateral LDLLT who survived >1 year and underwent routine pulmonary function testing. Acquired recipient pulmonary function was compared with lost donor pulmonary function at 1 year post-LDLLT., Results: The median age of the 38 recipients was 44 years (range, 8-62 years); 14 were men. The median age of the 76 donors was 41.5 years (range, 20-60 years); 50 were men. One year post-LDLLT, acquired recipient forced vital capacity was significantly greater than lost donor forced vital capacity (1889.5 ± 581.3 mL vs 1073.9 ± 661.6 mL; P < .001). Similarly, acquired recipient forced expiratory volume in 1 second at 1 year post-LDLLT was significantly greater than lost donor forced expiratory volume in 1 second (1646.8 ± 483.0 mL vs 1064.2 ± 534.5 mL; P < .001)., Conclusions: These results indicated that acquired recipient pulmonary function was better than lost donor pulmonary function in bilateral LDLLT., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: When induction therapy followed by surgery for locally advanced non-small cell lung cancer results in pathological complete response, the prognosis is excellent; however, relapses can occur. We analyzed the predictive factors for achieving pathological complete response and reviewed the clinicopathological features and surgical outcomes of locally advanced non-small cell lung cancer with pathological complete response., Methods: Between March 2005 and January 2015, 145 resections after induction therapy for locally advanced non-small cell lung cancer were performed; 38 cases achieved pathological complete response. Predictive factors for achieving pathological complete response were analyzed, and the clinicopathological features and surgical outcomes of 38 cases with pathological complete response were retrospectively reviewed., Results: Of 145 patients, 98 underwent induction chemoradiation and 47, induction chemotherapy. Squamous cell carcinoma occurred most frequently (n = 64), followed by adenocarcinoma (n = 53). Only squamous cell carcinoma was positively associated with achieving pathological complete response (p = 0.009). Of 38 patients with pathological complete response, 33 were men and the mean age was 67.0 ± 6.3 years; the clinical stages were IIA (n = 3), IIB (n = 2), IIIA (n = 26), and IIIB (n = 3). One patient died within 30 days post-surgery (2.6%). Eight recurrences occurred during the follow-up period; brain metastasis occurred most frequently. The 5-year overall and recurrence-free survival rates were 79.5% and 72.6%, respectively., Conclusions: Squamous cell carcinoma was identified as a positive predictive factor for achieving pathological complete response. Among patients undergoing lung cancer surgery after induction therapy with pathological complete response, brain metastasis occurred most frequently.

Background: Selecting the proper surgical approach for mediastinal tumors in the thoracic outlet is difficult. Video-assisted thoracoscopic surgery is ideal because of the less invasiveness; however, it is often difficult to resect tumors only by video-assisted thoracoscopic surgery due to the poor visualization of the cranial side of tumors. We report two successfully treated cases by using a dual approach consisting of the transmanubrial osteomuscular sparing technique and video-assisted thoracoscopic surgery for aiming both the less invasiveness and the good visualization of the cranial side of tumors., Case Presentations: We present two resected cases of the mediastinal tumor in the thoracic outlet. The first case was a 28-year-old woman and the second case was a 37-year-old man. They had a mediastinal tumor in the thoracic outlet which was detected on the roentgenogram. A definitive preoperative diagnosis was unavailable. The surgical resection was started with video-assisted thoracoscopic surgery in the both cases. After the dissection of the caudal side of the tumor, the dissection of the cranial side was judged to be difficult and risky because the tumor was located adjacent to major vessels and the good visualization of this side couldn't be acquired. Therefore, the transmanubrial approach was sequentially performed and complete resection was safely achieved. Postoperatively, although transient Horner syndrome appeared in both cases, they recovered from this syndrome and were discharged. The final diagnosis was schwannoma for both cases. Neither of the cases had any functional restriction of the upper extremity., Conclusions: This dual approach for mediastinal tumors in the thoracic outlet is useful in terms of safety and lower invasiveness.

Objectives: Although surgical resection after induction therapy (IT) for locally advanced non-small cell lung cancer (NSCLC) is a possible treatment option, pneumonectomy may be avoided owing to high-surgical risks. However, reports exist that pneumonectomy after IT has acceptable safety and favorable outcomes. We reviewed pneumonectomies after IT in terms of surgical outcomes, perioperative management, and complications., Methods: Between April 2004 and March 2015, 15 consecutive pneumonectomies were performed for locally advanced NSCLC after IT. Surgical outcomes, perioperative management, and complications were retrospectively reviewed., Results: Thirteen patients were men, and 6 pneumonectomies were right-sided. One pneumonectomy was performed after induction chemotherapy and 14 followed induction chemoradiation. In all 15 cases the bronchial stumps were covered with autologous tissues. Pedunculated mediastinal fat pad and pedunculated intercostal muscles were used in 4 and 11 cases, respectively. Although postoperative complications were seen in 12 patients (80.0%), with major complications (Clavien-Dindo classification ≥ IIIa) in 5 patients (33.3%), there were no deaths within 30 days after pneumonectomy. Overall 3- and 5-year survivals were 80.0 and 57.1%, respectively., Conclusions: Owing to high-surgical risks and complication rates, careful surgical technique and postoperative management are essential for successful pneumonectomy after IT.

Background: Early diagnosis of unilateral chronic lung allograft dysfunction (CLAD) is difficult because the unaffected contralateral lung functions as a reservoir in bilateral living-donor lobar lung transplantation (LDLLT). We previously reported the usefulness of 133 Xe ventilation scintigraphy for detection of unilateral change, but the supply of 133 Xe has been stopped globally. The present study aimed to examine the usefulness of inspiratory and expiratory computed tomography (I/E CT) volumetry for detection of unilateral change in CLAD patients., Methods: This was a retrospective single-center, observational study using prospectively collected data. A total of 58 patients who underwent bilateral LDLLT from August 2008 to February 2017 were analyzed. Respiratory function tests, I/E CT were prospectively conducted. ΔLung volume was defined as the value obtained by subtracting expiratory lung volume from inspiratory lung volume., Results: Fourteen (24%) cases were clinically diagnosed with CLAD, of which 10 (71%) were diagnosed as unilateral CLAD. ΔLung volume of bilateral lungs strongly correlated with forced vital capacity ( r = 0.92, P < 0.01) and forced expiratory volume in 1 second (r = 0.80, P < 0.01). Regardless the phenotypes (bronchiolitis obliterans syndrome or restrictive allograft syndrome) of CLAD, Δlung volume onset/baseline significantly decreased compared with that in the non-CLAD group. Among the 10 unilateral CLAD patients, 3 with clinically suspected unilateral rejection yet did not show a 20% decline in forced expiratory volume in 1 second. In 2 of these, Δlung volume of unilateral lungs on the rejection side decreased by 20% or more., Conclusions: Our findings suggest that I/E CT volumetry may be useful for assessment and early diagnosis of unilateral CLAD after bilateral LDLLT., Competing Interests: The authors declare no funding or conflicts of interests.

Purpose: Gastrointestinal complications after lung transplantation (LTx) are an important postoperative morbidity associated with malnutrition and the malabsorption of drugs. We reviewed our experience of managing gastrointestinal complications after LTx., Methods: Between June, 2008 and April, 2017, 160 lung transplants were performed at our institution, as living-donor lobar lung transplants in 77 patients, and as deceased-donor lung transplants in 83. We reviewed, retrospectively, the incidence, type and management of gastrointestinal complications., Results: Among the 160 LTx recipients, 58 (36.3%) suffered a collective 70 gastrointestinal complications, the most frequent being gastroparesis, followed by gastroesophageal reflux disease. Two complications were managed surgically, by Nissen fundoplication for gastroesophageal reflux disease in one recipient and Hartmann's operation for sigmoid colon perforation in one. The other 68 complications were managed medically. Two patients died of complications: one, of aspiration pneumonia caused by gastroparesis; and one, of panperitonitis caused by a gastric ulcer. There were no significant differences in overall survival or chronic lung allograft dysfunction-free survival between the patients with and those without gastrointestinal complications., Conclusions: Gastrointestinal complications are not uncommon in LTx recipients and may be serious; therefore, early detection and appropriate treatment are imperative. Surgical management is required for some complications, but most can be managed medically.

Objectives: The purpose of this study was to evaluate the effect of early tracheostomy in patients following lung transplantation and to determine its optimal timing and influence on clinical outcomes., Methods: We retrospectively reviewed records of 96 adult patients who underwent lung transplantation at our institution between August 2008 and January 2016. Time-to-tracheostomy was defined based on timing of the procedure: "early" if less than 3 days or "late" if 3 or more days after lung transplantation., Results: Forty-nine patients (51%) underwent tracheostomy 3.2 ± 1.8 days after lung transplantation. Among these patients, 21 patients (42.9%) underwent early tracheostomy and 28 patients (57.1%) underwent late tracheostomy. Multivariable logistic regression analysis indicated that preoperative performance status was a significant predictor for tracheostomy (p = 0.006, odds ratio 2.72). Patients in the early tracheostomy group began walking (p = 0.003) and oral feeding (p = 0.0006) earlier and had a shorter duration of mechanical ventilation (p = 0.04) and shorter length of intensive care unit (p = 0.01) and hospital stay (p = 0.04) than patients in the late tracheostomy group. No significant differences in postoperative walking (p = 0.06), oral feeding (p = 0.17), or length of hospital stay (p = 0.37) were observed between patients who underwent early tracheostomy and those who did not undergo tracheostomy., Conclusions: Early tracheostomy following lung transplantation decreased both intensive care and hospital stay, due to improved postoperative recovery, even in patients with poor preoperative conditions. Furthermore, length of hospital stay in patients with early tracheostomy was similar to that of patients without tracheostomy after lung transplantation.

Background: The validity of lobar lung transplantation (LT) has been established in both living-donor lobar lung transplantation (LDLLT) and cadaveric-donor lung transplantation (CLT). However, bronchial stump management in lobar LT has not been precisely documented. Thus, we retrospectively analyzed our strategies for bronchial stump management in lobar LT., Methods: Between June 2008 and August 2016, 145 LTs (72 LDLLTs and 73 CLTs) were performed at our institution. Bronchial stumps were left in 14 LDLLTs. Eight patients underwent bilateral CLTs with downsizing lobectomy. We avoided leaving donor bronchial stumps by lobar-to-lobar bronchial anastomosis, and left recipient bronchial stumps if necessary. We retrospectively reviewed the bronchial stump management methods and outcomes in these 22 patients., Results: Among the 14 LDLLTs, right-to-left inverted lobar LT and right single-lobe LT with left pneumonectomy were performed in 12 and 2 patients, respectively. Among the 8 CLTs, 11 lobectomies were performed because of oversized grafts and/or localized pneumonia. Twenty-three lobar-to-lobar bronchial anastomoses were performed, and there were 21 recipient bronchial stumps in total. Three bronchial stumps were left in the donor graft, the middle bronchus in all cases. No complications related to lobar-to-lobar bronchial anastomoses were observed. All bronchial stumps healed well without developing a bronchopleural fistula. The 3-year overall survival rate was 88.1% (95% confidence interval, 58.8%-97.0%)., Conclusions: We successfully avoided leaving bronchial stumps in the donor graft, except in the middle bronchus, by performing lobar-to-lobar bronchial anastomoses in lobar LTs. Excellent healing of lobar-to-lobar bronchial anastomoses and bronchial stumps was observed., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To overcome the problem of small-for-size grafts in standard living-donor lobar lung transplantation (LDLLT), we developed inverted LDLLT, in which a right lower lobe from 1 donor is implanted as a right graft and another right lower lobe from another donor is implanted as a left graft. We retrospectively analyzed the functions of inverted grafts vs noninverted grafts., Methods: Between 2008 and 2015, 64 LDLLTs were performed. Included were 35 LDLLTs whose recipients were adults and monitored for more than 6 months without developing chronic lung allograft dysfunction. Among them, 65 implanted lobes were eligible for this analysis. There were 31 right lower lobes implanted as right grafts (right-to-right group), 7 right lower lobes as inverted left grafts (right-to-left group), and 27 left lower lobes as left grafts (left-to-left group). We evaluated the graft forced vital capacity (G-FVC) and graft volume of the 65 lobes before and 6 months after LDLLT and compared them among the three groups., Results: Preoperatively, G-FVC in the right-to-left group (1,050 mL) was comparable to that in the right-to-right group (1,177 mL) and better than that in the left-to-left group (791 mL, p < 0.01). Six months after LDLLT, G-FVC in the right-to-left group (1,015 mL) remained comparable to that in the right-to-right group (1,001 mL) and better than that in the left-to-left group (713 mL, p = 0.047). The ratio of graft volume 6 months after LDLLT to the preoperative value was comparable., Conclusions: The functions of inverted grafts in inverted LDLLTs were satisfactory compared with those of noninverted grafts., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is considered useful for the staging and diagnosis of lung cancer or thoracic lymph node enlargement; however, little is known about its complications. Between July 2009 and November 2016, 413 patients underwent EBUS-TBNA, and four complications (0.97%) occurred. Here we report four cases involving complications of EBUS-TBNA, including mediastinitis (n = 2), obstructive pneumonia (n = 1), and airway obstruction requiring admission to the intensive care unit (n = 1). All patients recovered with appropriate medical treatment. Despite their low incidence, the complications associated with EBUS-TBNA can be serious., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In living-donor lobar lung transplantation, donor lobectomies must be performed carefully for both donors and recipients. Furthermore, the recipients undergo pneumonectomies rather than lobectomies. Occasionally, anastomosis of the pulmonary vessels is difficult in living-donor lobar lung transplantation because of the limited length of the pulmonary vessels in the graft. This report describes a successful case of pulmonary venoplasty using an autologous pericardial conduit, which was interposed between the superior pulmonary vein of the recipient and the inferior pulmonary vein of the donor in living-donor lobar lung retransplantation. This technique may be required for the success of living-donor lobar lung retransplantation., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Gastrointestinal complications sometimes occur after lung transplantation and remain a cause of postoperative morbidity. Superior mesenteric artery syndrome is caused by the compression of the duodenum by the superior mesenteric artery, but few reports have described superior mesenteric artery syndrome after lung transplantation. We herein report two cases of superior mesenteric artery syndrome as an early complication after lung transplantation. Both patients were emaciated and had lost weight before transplantation. They also lost an additional 2-4 kg early after transplantation. They were medically treated with enteral nutrition and recovered without recurrence of the syndrome. Since critically ill patients with pulmonary disease usually lose weight both before and early after lung transplantation, superior mesenteric artery syndrome is important to consider in the differential diagnosis of gastrointestinal complications after transplantation.