Two-stage Surgical Treatment of a Giant Solitary Fibrous Tumor Occupying the Thoracic Cavity

A solitary fibrous tumor (SFT) is a mesenchymal fibroblastic tumor inside the pleura, for which complete surgical resection is the standard treatment. For large SFTs, preoperative identification of tumor-feeding vessels using angiography is important for achieving complete resection without unexpected operative bleeding. Extensive adhesions can make resection difficult in a limited operative window, and pulmonary resection may be required to achieve complete SFT resection. Herein, we report successful resection of a large pleural SFT in a 39-year-old man without any complications using a 2-stage approach, in which ligation of the feeding vessels through small another operative window was the first step.

Treatment of Atrial Fibrillation in Elderly Patients with the Cox Maze Procedure Concurrently with Other Cardiac Operations

BACKGROUND: In elderly patients who have atrial fibrillation (AF), surgical ablation of the arrhythmia during cardiac surgery may be challenging. Despite the reported advantages of ablating AF with the Cox maze procedure (CMP), the addition of the CMP may complicate other cardiac operations. We evaluated the effect of the CMP in elderly patients concurrent with other cardiac operations. METHODS: From October 2007 to December 2015, we enrolled 27 patients aged >70 years who had AF and who underwent the CMP concurrently with other cardiac operations. The mean preoperative additive European System for Cardiac Operative Risk Evaluation score was 8±11 (high risk). RESULTS: Only 1 hospital death occurred (4%). The Kaplan-Meier method showed a high 5-year cumulative survival rate (92%). At mean follow-up of 51 months, 23 patients (89%) had sinus rhythm conversion. The postoperative left atrial dimensions did not significantly differ between the 8 patients who had reduction plasty for giant left atrium (53.4±7.5 cm) and the 19 patients who did not have reduction plasty (48.7±5.7 cm). CONCLUSION: In patients aged >70 years, concurrent CMP may be associated with a high rate of sinus rhythm conversion without increased surgical risk, despite the added complexity of the main cardiac procedure.

Simple Anastomotic Techniques for Coronary Artery Bypass Surgery in Patients with Small Coronary Arteries or a Marked Size Discrepancy Between the Coronary Artery and Graft

Different suture techniques have been used for anastomosis in coronary artery bypass graft surgery. Bypass surgery may be difficult for patients who have small coronary arteries or marked size discrepancies between target coronary arteries and grafts. For proximal and distal anastomoses, three continuous stitches are first placed in the heel and toe of the small coronary arteries; for sequential anastomosis, an interrupted eight-stitch technique is used. We applied these anastomotic suture techniques in patients requiring coronary artery bypass graft surgery, achieving an early angiographic patency rate of 100%.

Cost-Effectiveness of Carotid Endarterectomy versus Carotid Artery Stenting for Treatment of Carotid Artery Stenosis

BACKGROUND: Symptomatic or asymptomatic patients with significant carotid artery stenosis (range, 70% to 99%) generally undergo either carotid artery endarterectomy (CEA) or carotid artery stenting (CAS) to prevent stroke. In this study, we evaluated the cost effectiveness of these two treatment modalities. METHODS: A total of 47 patients (mean age, 67.1+/-9.1 years; male, 87.2%) undergoing either CEA (n=28) or CAS (n=19) for the treatment of significant carotid artery stenosis were enrolled in this study. Hospitalization costs were subdivided into three parts, namely pre-procedure, procedure and resource, and post-procedure costs. RESULTS: Total hospitalization costs were similar in both groups of CEA and CAS (6,377 thousand won [TW] vs. 6,703 TW, p=0.255); however, the total cost minus the pre-procedure cost was higher in the CAS group than in the CEA group (4,948 TW vs. 5,941 TW, p<0.0001). The pre-procedure cost of the CEA group was higher than that of the CAS group (1,429 TW vs. 762 TW, p<0.0001). However, the procedure and resource cost was higher in the CAS group because the resource cost was approximately three times higher in the CAS group than in the CEA group. The post-procedure cost was higher in the CEA group because hospital stays were approximately two times longer. CONCLUSION: The total hospitalization cost was not different between the CEA and the CAS groups. The pre-procedure cost was high in the CEA group, but the cost from procedure onset to discharge, including the resource cost, was significantly lower in this group.

Aortic Valve Replacement Using Continuous Suture Technique in Patients with Aortic Valve Disease

BACKGROUND: The continuous suture (CS) technique has several advantages as a method for simple, fast, and secure aortic valve replacement (AVR). We used a simple CS technique without the use of a pledget for AVR and evaluated the surgical outcomes. MATERIALS AND METHODS: Between October 2007 and 2012, 123 patients with aortic valve disease underwent AVR alone (n=28) or with other concomitant cardiac procedures (n=95), such as mitral, tricuspid, or aortic surgery. The patients were divided into two groups: the interrupted suture (IS) group (n=47), in which the conventional IS technique was used, and the CS group (n=76), in which the simple CS technique was used. RESULTS: There were two hospital deaths (1.6%), which were not related to the suture technique. There were no significant differences in cardiopulmonary bypass time or aortic cross-clamp time between the two groups for AVR alone or AVR with concomitant cardiac procedures. In the IS group, two patients had prosthetic endocarditis and one patient experienced significant perivalvular leak. These patients underwent reoperations. In the CS group, there were no complications related to the surgery. Postoperatively, the two groups had similar aortic valve gradients. CONCLUSION: The simple CS method is useful and secure for AVR in patients with aortic valve disease, and it may minimize surgical complications, as neither pledgets nor braided sutures are used.

Predictive Factors of Sustained Sinus Rhythm and Recurrent Atrial Fibrillation after the Maze Procedure

BACKGROUND: We examined perioperative predictors of sustained sinus rhythm (SR) in patients undergoing the Cox maze operation and concomitant cardiac surgery for structural heart disease. MATERIALS AND METHODS: From October 1999 to December 2008, 90 patients with atrial fibrillation (AF) underwent the Cox maze operation and other concomitant cardiac surgery. Eighty-nine patients, all except for one postoperative death, were followed-up with serial electrocardiographic studies, 24-hour Holter monitoring tests, and regular echocardiographic studies. RESULTS: Eighty-nine patients undergoing the maze operation were divided into two groups according to the presence of SR. At the time of last follow-up (mean follow-up period, 51.0+/-30.8 months), 79 patients (88.8%) showed SR (SR group) and 10 patients (11.2%) had recurrent AF (AF group). Factors predictive of sustained SR were the immediate postoperative conversion to SR (odds ratio, 97.2; p=0.001) and the presence of SR at the 6th month postoperatively (odds ratio, 155.7; p=0.002). Duration of AF, mitral valve surgery, number of valves undergoing surgery, left atrial dimension, and perioperative left ventricular dimensions and ejection fractions were not predictors of postoperative maintenance of SR. CONCLUSION: Immediate postoperative SR conversion and the presence of SR at the 6th postoperative month were independent predictors of sustained SR after the maze operation.

Postintubation Tracheal Ruptures: A case report

Tracheobronchial ruptures (TBR) rarely complicate surgical procedures under general anesthesia. Seemingly uneventful intubations can result in injury to the trachea, which often manifests as hemoptysis and subcutaneous emphysema. We present 2 patients with postintubation TBR who were treated surgically and discuss considerations in the management of this potentially lethal injury.

A Chronic Traumatic Diaphragmatic Hernia Presenting 36 Years after Preceding Injury: A Case Report / 대한구급학회지

We report a distinctive case of a large traumatic diaphragmatic hernia (TDH) that presented 36-years after the preceding injury. We believe this case represents the most delayed (TDH) presentation ever reported in Korea. This paper describes the particular presentation, including the operative and postoperative management of this patient. We also review the management of long delayed TDH presentation and the postoperative issues concerning thoracic cavity dead space and propensity of the repaired diaphragm for developing abdominal compartment syndrome.

Intramural Dissection and Mucosal Laceration of the Esophagus in a Patient Who Was on Antiplatelets Medication : A case report / 대한흉부외과학회지

Intramural esophageal dissection is a rare disorder that's characterized by a lengthy laceration between the mucosal and submucosal layers of the esophageal wall, and the esophageal wall is without perforation. The three different types of acute esophageal injury are a mucosal tear (Mallory-Weiss syndrome), full-thickness rupture (Boerhaave's syndrome) and intramural esophageal dissection. Most intramural esophageal dissections respond to conservative management with a very good prognosis. This rare condition should be considered in patients who present with acute chest pain, dysphagia or odynophagia, and particularly in the presence of a bleeding disorder or where there has been recent administration of antiplatelet medication, anticoagulants or thrombolytics to avoid inappropriate treatment with surgery. We present here a rare case of intramural dissection of the esophagus that occurred when the patient was taking antiplatelet medication.

Pedunculated subpleural lipoma with incomplete torsion: A case report / 대한내과학회지

Lipoma is a common benign neoplasm, but lipoma arising from the pleura is rare. Most pleural lipomas are asymptomatic and are discovered incidentally on chest radiographs. Here we report an unusual case of a pedunculated subpleural lipoma with incomplete torsion in a 29-year-old woman who presented with flank pain. On chest radiography, there was a well-defined, ellipsoidal, homogeneous, radioopaque mass in the left lower lobe. An intrathoracic tumor was suspected, and video-assisted thoracic surgery was performed to establish the final diagnosis. The resected tumor was a 10 X 5 cm sized pedunculated pleural mass. The cut surface showed a yellow, well-circumscribed mass with areas of hemorrhage. Histologically, the tumor was composed of mature adipose tissue with fibrous septae composed of fibroblasts. The outer surface of the tumor was covered by mesothelial cells. Some areas were hypercellular, and occasional mitoses were found, but neither lipoblasts nor atypical mitoses were identified.

Granular Cell Tumor Arising from the Left Main Bronchus : A case report / 대한흉부외과학회지

Granular cell tumors (GCT) are uncommon benign neoplasms. Their location is mostly in the the skin, tongue, and breast; appearance in other parts of the body is rare, but it has been reported. They have also been reported to occur synchronously in multiple organs and metachronously in a single organ. The incidence of GCTs in the tracheobronchial tree is unknown and pulmonary GCTs are uncommon, with approximately 100 reported cases in the literature. We present the case of a 33-year-old man with a granular cell tumor of the left main bronchus. The tumor was found at bronchoscopy performed to exclude suspected endobronchial mass with symptoms of pneumonia. Biopsies revealed the histological pattern of a benign granular cell tumor. He underwent resection of the left main bronchus followed by end to end anastomosis of left main bronchus. He has not had any recurrence of the tumor during the 1 year follow-up.

Clinical Results of Pulmonary Resection for Hemoptysis of Inflammatory Lung Disease / 대한흉부외과학회지

BACKGROUND: To assess the outcome of pulmonary resection in the management of hemoptysis caused by benign inflammatory lung disease. MATERIAL AND METHOD: A longitudinal cohort study of 45 consecutive patients who were presented with hemoptysis and were treated with pulmonary resection from January 1995 to May 2004. The predictive preoperative risk factors of morbidity and recurrence of hemoptysis were analyzed. The mean age of the patients was 47.1 years. The mean follow-up was 35+/-34 months. RESULT: The overall hospital mortality rate was 4.4% (2/45). Postoperative complications occurred in 8 patients (18.6%). Complications were more common in patients who received blood transfusion than non-transfused patients (p=0.002). Patients with tuberculous destroyed lung disease had more amount of preoperative hemoptysis (p=0.002), more probability of transfusion (p=0.001), more probability of undergoing pneumonectomy (p=0.039) and more probability of postoperative morbidity. Patients of undergoing pneumonectomy had more probability of reoperation due to postoperative bleeding (p=0.047). Hemoptysis recurred in five patients but three had been subsided and two sustained during follow-up. A latter two patients had been prescribed with antituberculosis medication due to relapse of tuberculosis. CONCLUSION: A tuberculous destroyed lung disease has a higher rate of postoperative morbidity than other inflammatory lung diseases. A pneumonectomy in patients of inflammatory lung disease should be performed with great caution especially because of postoperative bleeding. Future study with longer and larger follow-up might show the reasons of recurrence of hemoptysis.

Malignant Gastrointestinal Stromal Tumor of the Esophagus: One case report / 대한흉부외과학회지

Gastrointestinal stromal tumors (GISTs) are rare, but potentially aggressive tumors. GISTs are generally found in the stomach or small intestine and less commonly in the colon, rectum, or an intra-abdominal sites but have rarely been documented in the esophagus. GISTs were definded as the most common mesenchymal tumors of the gastrointestinal tract for which there is incomplete understanding of their lineage, while their relationship with differenciated. We reported a very rare case of GISTs of lower esophagus in a 66-year-old woman with relevant literature review.

Huge Intraabdominal and Thoracic Desmoid Tumor: Surgical experience in one case / 대한흉부외과학회지

Desmoid tumors are benign neoplasms with high rates of recurrence. A case of huge desmoid tumor of the intrathoracic and intraabdominal space is presented. The patient was treated with resection, which involved hepatic left lobectomy and diaphragmatic resection and partial pericardiectomy and wedge resection of left lower lobe of lung. The resulting defect over the pericarium and diaphragm was reconstructed by bovine pericardium and Marlex mesh. Prevention of presumed local recurrence of desmoid tumors requires wide excision margin.

Bronchogenic Squamous Cell Carcinoma in Patient with Swyer-James Syndrome: One Case Report / 대한흉부외과학회지

Swyer-James syndrome is a rare disease with patients presenting with unilateral hyperlucent lungs and hypoperfusion due to hypoplasia of the pulmonary artery and bronchiolitis obliterans. A unilateral hyperlucent lung generally develops after a lower respiratory tract infection during early childhood. In extremely rare cases, an association of bronchogenic carcinoma with Swyer-James syndrome has been reported. We report a case of bronchogenic squamous cell carcinoma associated with Swyer-James syndrome that performed right upper lobectomy and lymph node dissection with a relevant literature review.

Coarctation of the Aorta Associated with Chronic Thoracic Aortic Aneurysm: A case report / 대한흉부외과학회지

A 49-year-old woman had thoracic back pain for several years. Chest CT scan and MRI angiography revealed descending thoracic aortic aneurysm with a maximum diameter of 69 mm. Thoracic aortography showed not only the aortic aneurysm, but also coarctation of descending thoracic aorta at the level of aortic hiatus of the diaphragm. Intercostal artery arising Adamkiewicz artery was found in descending thoracic aortic aneurysm just above the coarctation. The aneurysm with coarctation of the aorta was successfully repaired with prosthetic graft replacement under left atrio-femoral bypass.

Mucosal Resection in the Corrosive Esophageal Stricture: A new technique / 대한흉부외과학회지

Balloon dilatation is a popular method in corrosive esophageal stricture but swallowing difficulty due to recurrent or intractable stricture even in the repeated dilatation needs a esophageal reconstruction. Stomach, colon or jejunum has been used for the prosthesis of esophagus. Many problems such as leakage in anastomosis site, stricture, reflex, adhesion, strangulation, and engrafted esophageal cancer are associated with the remnant esophageal stricture in the esophago-gastrostomy and esophageal bypass surgery. Easy and reproduceable method of operation with lower complication and without functional disability is needed. A new operation method of mucosal resection and plasty is introduced in the corrosive esophageal stricture that are not relieved by repeated dilatation.

Lipoblastoma of the Neck and Mediastinum: 1 case report / 대한흉부외과학회지

Lipoblastoma are rare benign tumors arising from the fetal-embryonal fat that occur almost exclusively in children. About 70% of them arise in the limbs but several other sites have been reported. We have treated a 3-year-old boy who had a benign lipoblastoma in left posterior mediastinum and left supraclavicular area. CT scanning demonstrated a mass of principally fat attenuation which had a compressive effect on normal intrathoracic structures. The tumor was resected completely without complication from the left posterior mediastinum and left supraclavicular area. The tumor mass was yellowish in color and it was histopathologically confirmed to be a lipoblastoma.

A case of Bronchogenic Cyst in Diaphragm / 대한흉부외과학회지

Isolated bronchogenic cysts of the diaphragm are rare abnormalities. They are usually asymptomatic unless secondarily infected or large enough to cause compression of vital structures. The patient was a 31-year-old man and had no symptoms except mild postprandial epigastric discomfort. The chest X-ray and chest C-T examination revealed a mediastinal mass at the left cardio-vertebro-phrenic angle. We performed the operation under the impression of solid mass at mediastinum. We revealed that the mass was bronchogenic cyst in diaphragm. Therefore we report this case with review of literatures.

Congenital coronary arteriovenous fistula combined with ASD

Coronary arteriovenous fistula (CAF) is most common form of hemodynamically significant coronary anomaly. CAF combined with atrial septal defect (ASD), however, constitutes an uncommon subgroup of CAF. We present a case of congenital CAF combined with secondum ASD, which are manifested by congestive heart failure. These anomalies were identified by transthoracic echocardiography and coronary angiography respectively. These ASD and CAF were closed by operation successfully without any complication.