Mitsunori Higuchi1, Jin Ye Yeo2
1Department of Thoracic Surgery, Aizu Medical Center, Fukushima Medical University, Aizuwakamatsu, Japan; 2CCTS Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. CCTS Editorial Office, AME Publishing Company. Email: ccts@amegroups.com
This interview can be cited as: Higuchi M, Yeo JY. Readers’ Choice: Author Interview with Dr. Mitsunori Higuchi. Ann Esophagus. 2024. Available from: https://ccts.amegroups.org/post/view/readers-rsquo-choice-author-interview-with-dr-mitsunori-higuchi.
Expert introduction
Dr. Mitsunori Higuchi (Figure 1) is a professor of Thoracic Surgery at Aizu Medical Center, Fukushima Medical University in Japan, where he participates clinically in thoracic surgical intensive care and chemotherapy for thoracic malignancies. He received his medical degree from Fukushima Medical University and trained at Fukushima Medical University Hospital in Japan and the University of Maryland in the US. Dr.Higuchi is board-certified in general and thoracic surgery. He is a member of the Japan Surgical Association, Japanese Association of Chest Surgery, International Association for the Study of Lung Cancer (IASLC), European Society of Medical Oncology (ESMO), and so on. His clinical interests are the multidisciplinary therapy of lung cancer, especially for advanced non-small cell lung cancer (NSCLC), and the management of thoracic empyema regardless of medical or surgical procedure. He is also interested in applying artificial intelligence (AI) to clinical settings and his team developed novel AI for the detection of pulmonary nodules on chest radiographs with high accuracy. His team also developed a novel imaging system for the prediction of mediastinal lymph node metastases of NSCLC on chest CT scans before surgery. They have now proceeded to conduct a radiogenomics study to detect genetic mutations in NSCLC from the images of chest CT scans using texture analysis with computer scientists and his senior colleague.
Dr. Higuchi’s article, “Current status and prospect of medical and surgical management for thoracic empyema”, published in our journal, has received an outstanding readership and entered the journal’s Most Read Article List.
Figure 1 Dr. Mitsunori Higuchi
Interview
CCTS: What initially drew you into the field of thoracic surgery? How has your clinical experience shaped your interest in chronic thoracic empyema?
Dr. Higuchi: When I graduated from medical school, the prognoses of increasing lung cancer were too poor to be challenged. However, we had some new-generation anti-cancer medicines, such as paclitaxel, gemcitabine, vinorelbine, and so on, which were considered to be promising medicines. At the same time, video-assisted thoracic surgery (VATS) has appeared and quickly become popular in place of thoracotomy all over the world. These changes encouraged me to specialize in thoracic surgery, aiming for the improvement of prognosis. Furthermore, with an aging society, intrathoracic infections such as pneumonia accompanied by thoracic empyema are increasing, and these pathophysiological conditions are so diverse that we have to perform various kinds of treatments for each patient according to their disease conditions. These problems also encouraged me to be interested in thoracic empyema.
CCTS: Chronic empyema is often associated with long-term complications. What are some of the most common challenges you encountered in managing chronic thoracic empyema, and how do you approach these complex cases?
Dr. Higuchi: Each chronic empyema is always accompanied by various cavities. Some cavities are with fistula, others without. The latter is relatively easy to treat with muscle or/and omental plombage and thoracoplasty. However, the former is sometimes difficult to deal with. The most important key factor to cure chronic empyema is to eliminate cavities. However, if the patients have cavities with fistula, we must close the fistula with Endoscopic Watanabe Spigot (EWS), cyanoacrylate, fibrin glue, and so on, even though these methods are not always successful. We sometimes use other medical devices that are not supposed to be used to make successful attempts because there is little evidence to resolve such a difficult problem using those devices.
CCTS: What do you believe are the most important factors contributing to the progression of empyema, and to what extent can early intervention help mitigate these complications?
Dr. Higuchi: If thoracic empyema had occurred after lung resection, we surgeons must be careful during surgery to injure the bronchi and lungs with surgical devices such as needles and stapling devices. We must be especially careful when we perform right lower lobectomy as bronchial fistula occurs infrequently after surgery. I sometimes add a plombage of pericardial fat pad to the stump of the right lower bronchus depending on the patient’s condition.
When the empyema has nothing to do with surgery, the most common cause of empyema is pneumonia. Aspiration pneumonia-derived empyema is occasionally observed. Medical staff must instruct patients to clean the oral environment. If the patients have dental caries, we must recommend them to have their problems in the oral cavities resolved. It is very important to prevent pulmonary infection.
CCTS: In your article, you advocate for a standardized guideline for the treatment of empyema. How do you envision such guidelines being developed, and what key aspects should be included to ensure they are applicable across different clinical settings?
Dr. Higuchi: In Japan, a new guideline for the treatment of thoracic empyema has been created recently, which was edited considering already published guidelines by the American Association for Thoracic Surgery (2017) and the British Thoracic Society (2005). The publication of this new guideline is a great pleasure for Japanese thoracic surgeons. However, there are some problems that do not have a high evidence level. The guideline for thoracic empyema can not cover everything because there are various pathophysiological conditions, and a few randomized controlled trials exist in this field. Therefore, the guideline committee had to adopt case reports. I think the guideline for thoracic empyema can describe some clinical case reports, which will be helpful for thoracic surgeons and pulmonary physicians to share clinical information in such a situation where there is little evidence.
CCTS: What are some emerging treatments or techniques in the management of thoracic empyema that you find particularly promising, and how might these change the way we approach patient care in the future?
Dr. Higuchi: In the field of chronic empyema, surgical intervention is the most promising treatment. In the acute phase, new attempts have been performed as minimally invasive treatments. Fibrinolysis including urokinase, streptokinase, tissue plasminogen activator (tPA), and deoxyribonuclease (DNase) is promising as an alternative to surgery. Before becoming chronic phase, we must achieve the cure of acute phased thoracic empyema with the methods mentioned above and surgical intervention.
CCTS: Looking ahead, what do you consider to be the most pressing challenge in the management of thoracic empyema, and what steps should the medical community take to address them?
Dr. Higuchi: In this field, experience level is so important with evidence level. We must fully understand the guidelines and also inherit our great experience to the younger generation. The pathological condition of thoracic empyema is diverse and so complicated, but early treatment will more likely succeed in the cure of this pathology. We thoracic surgeons must make an effort to enlighten this pathology to physicians, other medical staff, and to all citizens.
CCTS: As a recognized expert in the field of thoracic surgery, what advice would you like to give to young surgeons or physicians who are interested in specializing in thoracic surgery or pulmonary medicine?
Dr. Higuchi: There are many issues to be resolved in the field of thoracic diseases. Lung cancer is one of the urgent and the biggest problems. Many new anti-cancer medicines are developed one after another every year, and chemotherapy is now very complicated to practice. Surgical operations are heading to minimally invasive surgery such as VATS (video-assisted thoracic surgery) and RATS (robot-assisted thoracic surgery). Furthermore, the importance of perioperative chemotherapy is increasing based on recent clinical studies. For young surgeons and physicians, these trends are attractive, however, understanding and overcoming the pitfalls during surgery and in clinical practice are more important. In other words, application skills and wisdom are essential for every surgeon and physician.
In the field of thoracic empyema, there is little evidence to date. These facts make it difficult to produce the standard of care. I expect young surgeons and physicians to be interested in the fields with little evidence, and they will unravel new evidence. I also would like to ask them to hold a challenging mind, continue daily efforts to obtain advanced skills, and provide patients their excellent care with warm hearts.