Staged Surgical Treatment of Primary Aortoesophageal Fistula / 대한흉부외과학회지

Aortoesophageal fistula (AEF) is a rare and potentially fatal disease that causes massive gastrointestinal bleeding. Therefore, early diagnosis and treatment are essential to prevent mortality. Controlling the massive bleeding is the most important aspect of treating AEF. The traditional surgical treatment was emergent thoracotomy, but intraoperative or perioperative mortality was high. We report a case of a patient presenting with hematemesis who was successfully treated by a staged treatment, in which bridging thoracic endovascular aortic repair was followed by delayed surgical repair of the esophagus and aorta.

Erratum: Staged Surgical Treatment of Primary Aortoesophageal Fistula

One author was missed.

Preoperative Risk Factors for Pathologic N2 Metastasis in Positron Emission Tomography-Computed Tomography–Diagnosed N0–1 Non-Small Cell Lung Cancer

BACKGROUND@#Accurate mediastinal lymph node staging is vital for the optimal therapy and prognostication of patients with lung cancer. This study aimed to determine the preoperative risk factors for pN2 disease, as well as its incidence and long-term outcomes, in patients with clinical N0–1 non-small cell lung cancer.@*METHODS@#We retrospectively analyzed patients who were treated surgically for primary non-small cell lung cancer from November 2005 to December 2014. Patients staged as clinical N0–1 via chest computed tomography (CT) and positron emission tomography (PET)-CT were divided into two groups (pN0–1 and pN2) and compared.@*RESULTS@#In a univariate analysis, the significant preoperative risk factors for pN2 included a large tumor size (p=0.083), high maximum standard uptake value on PET (p<0.001), and central location of the tumor (p<0.001). In a multivariate analysis, central location of the tumor (p<0.001) remained a significant preoperative risk factor for pN2 status. The 5-year overall survival rates were 75% and 22.9% in the pN0–1 and pN2 groups, respectively, and 50% and 78.2% in the patients with centrally located and peripherally located tumors, respectively. In a Cox proportional hazard model, central location of the tumor increased the risk of death by 3.4-fold (p<0.001).@*CONCLUSION@#More invasive procedures should be considered when pre-operative risk factors are identified in order to improve the efficacy of diagnostic and therapeutic plans and, consequently, the patient’s prognosis.

Staged Surgical Treatment of Primary Aortoesophageal Fistula

Aortoesophageal fistula (AEF) is a rare and potentially fatal disease that causes massive gastrointestinal bleeding. Therefore, early diagnosis and treatment are essential to prevent mortality. Controlling the massive bleeding is the most important aspect of treating AEF. The traditional surgical treatment was emergent thoracotomy, but intraoperative or perioperative mortality was high. We report a case of a patient presenting with hematemesis who was successfully treated by a staged treatment, in which bridging thoracic endovascular aortic repair was followed by delayed surgical repair of the esophagus and aorta.

Erratum: Staged Surgical Treatment of Primary Aortoesophageal Fistula / 대한흉부외과학회지

One author was missed.

Preoperative Risk Factors for Pathologic N2 Metastasis in Positron Emission Tomography-Computed Tomography–Diagnosed N0–1 Non-Small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Accurate mediastinal lymph node staging is vital for the optimal therapy and prognostication of patients with lung cancer. This study aimed to determine the preoperative risk factors for pN2 disease, as well as its incidence and long-term outcomes, in patients with clinical N0–1 non-small cell lung cancer. METHODS: We retrospectively analyzed patients who were treated surgically for primary non-small cell lung cancer from November 2005 to December 2014. Patients staged as clinical N0–1 via chest computed tomography (CT) and positron emission tomography (PET)-CT were divided into two groups (pN0–1 and pN2) and compared. RESULTS: In a univariate analysis, the significant preoperative risk factors for pN2 included a large tumor size (p=0.083), high maximum standard uptake value on PET (p<0.001), and central location of the tumor (p<0.001). In a multivariate analysis, central location of the tumor (p<0.001) remained a significant preoperative risk factor for pN2 status. The 5-year overall survival rates were 75% and 22.9% in the pN0–1 and pN2 groups, respectively, and 50% and 78.2% in the patients with centrally located and peripherally located tumors, respectively. In a Cox proportional hazard model, central location of the tumor increased the risk of death by 3.4-fold (p<0.001). CONCLUSION: More invasive procedures should be considered when pre-operative risk factors are identified in order to improve the efficacy of diagnostic and therapeutic plans and, consequently, the patient’s prognosis.

Heterotopic Ossification of the Xiphoid Process after Abdominal Surgery for Traumatic Hemoperitoneum

Heterotopic ossification of the xiphoid process is extremely rare, with only three cases previously reported. However, the surgical pathology for postoperative elongation of the xiphoid process after abdominal surgery has not yet been reported. We report a case of the postoperative elongation of the xiphoid process, 8 years after abdominal surgery for traumatic hemoperitoneum in a 53-year-old man. The patient underwent surgical excision of the elongated mass of the xiphoid process. Histopathology revealed multiple exostoses. Heterotopic ossification can occur after surgical trauma to soft or bone tissue. Surgical excision with primary closure is the treatment of choice for symptomatic heterotopic ossification.

Myasthenia Gravis with Thymoma Recurrence 20 Years after Thymectomy: What Is the Optimal Follow-up Duration?

Thymoma occurs in about 20% of patients with myasthenia gravis (MG), but the recurrence of thymoma has rarely been reported. A 68-year-old man presented with ptosis and weakness of the neck muscles. He had undergone thymectomy for ocular MG with invasive thymoma 20 years previously. Chest computed tomography revealed recurrence of the thymoma. This 20-year period is, to our knowledge, the longest reported interval for recurrence of an MG-associated thymoma. The literature on the optimal follow-up duration after thymectomy is reviewed.

Selective Carotid Shunting Based on Intraoperative Transcranial Doppler Imaging during Carotid Endarterectomy: A Retrospective Single-Center Review

BACKGROUND: Carotid endarterectomy (CEA) with selective shunting is the surgical method currently used to treat patients with carotid artery disease. We evaluated the incidence of major postoperative complications in patients who underwent CEA with selective shunting under transcranial Doppler (TCD) at our institution. METHODS: The records of 45 patients who underwent CEA with TCD-based selective shunting under general anesthesia from November 2009 to June 2015 were reviewed. The risk factors for postoperative complications were analyzed using univariate and multivariate analysis. RESULTS: Preoperative atrial fibrillation was observed in three patients. Plaque ulceration was detected in 10 patients (22.2%) by preoperative computed tomography imaging. High-level stenosis was observed in 16 patients (35.5%), and 18 patients had contralateral stenosis. Twenty patients (44.4%) required shunt placement due to reduced TCD flow or a poor temporal window. The 30-day mortality rate was 2.2%. No cases of major stroke were observed in the 30 days after surgery, but four cases of minor stroke were noted. Univariate analysis showed that preoperative atrial fibrillation (odds ratio [OR], 40; p=0.018) and ex-smoker status (OR, 17.5; p=0.021) were statistically significant risk factors for a minor stroke in the 30-day postoperative period. Analogously, multivariate analysis also found that atrial fibrillation (p<0.001) and ex-smoker status (p=0.002) were significant risk factors for a minor stroke in the 30-day postoperative period. No variables were identified as risk factors for 30-day major stroke or death. No wound complications were found, although one (2.2%) of the patients suffered from a hypoglossal nerve injury. CONCLUSION: TCD-based CEA is a safe and reliable method to treat patients with carotid artery disease. Preoperative atrial fibrillation and ex-smoker status were found to increase the postoperative risk of a small embolism leading to a minor neurologic deficit.

The Risk Factors and Outcomes of Acute Kidney Injury after Thoracic Endovascular Aortic Repair

BACKGROUND: We aimed to evaluate the incidence, predictive factors, and impact of acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR). METHODS: A total of 53 patients who underwent 57 TEVAR operations between 2008 and 2015 were reviewed for the incidence of AKI as defined by the RIFLE (risk, injury, failure, loss, and end-stage kidney disease risk) consensus criteria. The estimated glomerular filtration rate was determined in the perioperative period. Comorbidities and postoperative outcomes were retrospectively reviewed. RESULTS: Underlying aortic pathologies included 21 degenerative aortic aneurysms, 20 blunt traumatic aortic injuries, six type B aortic dissections, five type B intramural hematomas, three endoleaks and two miscellaneous diseases. The mean age of the patients was 61.2+/-17.5 years (range, 15 to 85 years). AKI was identified in 13 (22.8%) of 57 patients. There was an association of preoperative stroke and postoperative paraparesis and paraplegia with AKI. The average intensive care unit (ICU) stay in patients with AKI was significantly longer than in patients without AKI (5.3 vs. 12.7 days, p=0.017). The 30-day mortality rate in patients with AKI was significantly higher than patients without AKI (23.1% vs. 4.5%, p=0.038); however, AKI did not impact long-term survival. CONCLUSION: Preoperative stroke and postoperative paraparesis and paraplegia were identified as predictors for AKI. Patients with AKI experienced longer average ICU stays and greater 30-day mortality than those without AKI. Perioperative identification of high-risk patients, as well as nephroprotective strategies to reduce the incidence of AKI, should be considered as important aspects of a successful TEVAR procedure.

A Case of Congenital Bronchial Defect Resulting in Massive Posterior Pneumomediastinum: First Case Report / 대한주산의학회잡지

Bronchial defects in neonates are known to occur very rarely as a complication of mechanical ventilation or intubation. This causes persistent air leakage that may form massive pneumomediastinum or pneumothorax, leading to cardiac tamponade or cardiorespiratory deterioration. Early diagnosis and treatment of bronchial defects are essential, as they can be accompanied by underlying severe lung parenchymal diseases, especially in preterm infants. We encountered an extremely low birth weight infant with an air cyst cavity in the posterior mediastinum that displaced the heart anteriorly, thereby causing cardiopulmonary deterioration. During exploratory-thoracotomy, after division of the air cyst wall (mediastinal pleura), we found a small bronchial defect in the posterior side of the right main bronchus. The patient had shown respiratory distress syndrome at birth, and she was managed by constant low positive pressure ventilation using a T-piece resuscitator after gentle intubation. As the peak inspiratory pressure was maintained low throughout and because intubation was successful at the first attempt without any difficulty, we think that the cause of the defect was not barotrauma or airway injury during intubation. The fact that the margin of the defect was very clear also suggested a congenital origin. To our knowledge, this is the first case of congenital bronchial defect in English literature.

A Case of Simultaneous Bilateral Spontaneous Pneumothorax Combined with Hemopneumothorax

Bilateral pneumothorax is very rare in primary spontaneous pneumothorax patients. This condition can cause chest pain, dyspnea, and even lead to tension pneumothorax. Spontaneous hemopneumothorax can be lethal due to massive bleeding and hypovolemic shock. This condition requires precise decision making and emergency management. We report on a case of simultaneous bilateral spontaneous pneumothorax combined with hemopneumothorax in a healthy 21-year-old male patient with chest discomfort. In the emergency department, closed thoracostomy was performed for decompression of hemopneumothorax, with drainage of 850 mL of blood. Then bilateral video-assisted thoracoscopic surgery was performed successfully.

Subphrenic Esophageal Diverticulum Associated with Esophageal Dysmotility and Leiomyoma / 대한내과학회지

Lower esophageal diverticula are frequently related to esophageal motor disorders. An epiphrenic esophageal diverticulum can also have a mechanical cause, such as an esophageal web, benign stricture, or leiomyoma. For a good therapeutic outcome, symptomatic patients with an esophageal diverticulum require a tailored approach. Therefore, it is important to evaluate motor disorders and other associated diseases in a patient with an esophageal diverticulum before devising a therapeutic strategy. We report a case of subphrenic diverticulum associated with an esophageal leiomyoma and motility disorder in a 58-year-old man who had suffered from intermittent regurgitation of food and epigastric soreness.

Cystic Mass on Right Atrium of Unusual Form of Chiari's Network: A Case Report

Chiari's networks are present in 1.5% to 4% of the population. They are a congenital disease characterized by a remnant of the right valve of sinus venosus and rarely have clinical significance. Chiari's network, as the name implies, has network-like shape, but there are other forms of appearance. We have experienced a case of a 60-year-old woman who had a cystic mass on the right atrium. Surgical treatment was performed forthe mass removal and differential diagnosis of the mass. There was no evidence of other tumor, but Chiari's network. As cystic form of Chiari's network have not been reported before, it is the first report of cystic form of Chiari's network.

Bilateral Mediastinal Lymphangiohemangiomas Containing Anomalous Venous Components - A case report -

Lymphangiohemangiomas of the mediastinum are exceedingly rare and few cases have been published in the English literature. This report may be the only reported case in which lymphangiohemangiomas were found bilaterally. We report a case of a 7-year-old boy with an incidental finding of an abnormal mediastinal shadow on a chest X-ray. The chest CT showed a large mass in the left superior mediastinum and another in the right posterior mediastinum. The left mass had anomalous venous channels connected to the left innominate vein, and the right mass to the left atrium. We performed an excision of the mass in the left side first and then the right side one month later. Anomalous venous channels were dissected carefully and ligated. There were no complications and no signs of recurrence 30 months after the operation.

Thoracic Duct Cyst in Mediastinum: A case report

The thoracic duct cyst is an extremely rare cystic lesion in the mediastinum. Surgical treatment of the cyst is necessary to confirm histologic diagnosis and prevent potential complications such as spontaneous or traumatic rupture of the cyst and chylothorax.

Hybrid Procedure for Aortic Arch Aneurysm: Arch Vessels Debranching and Thoracic Endovascular Aortic Repair?: 2 case reports / 대한흉부외과학회지

Conventional surgery for aortic arch aneurysms have many postoperative complications and a high mortality rate due to prolonged cardiopulmonary bypass time, especially in high risk patients. In this report, we present two cases of a hybrid procedure that involves open brachiocephalic bypass with concomitant endovascular arch stent grafting in high risk patients with distal aortic arch aneurysm.

Synovial Sarcoma Arising from the Chest Wall in a Child: A case report / 대한흉부외과학회지

Synovial sarcoma is a malignant soft-tissue tumor that most commonly occurs in the extremities of young adults. There have been several cases of synovial sarcomas of the pleural and lung reported, but synovial sarcoma arising from the chest wall in childhood is very rare. Here we report a case of synovial sarcoma arising from the chest wall in a 3 year-old female patient. The tumor was completely resected. No adjuvant therapy was given. The patient is well 3 years after the operation.

Visceral Pleural Invasion as a Prognostic Factor for Recurrence in Resected IB Non-small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Several trials have reported on whether adjuvant chemotherapy for resected stage IB non-small cell lung cancer is needed. The aim of our study was to investigate prognostic factors for recurrence to help identify patients who should receive adjuvant chemotherapy. MATERIAL AND METHOD: We reviewed the cases of 48 stage IB non-small cell lung cancer patients between 1997 and 2006. Disease-free survival and overall survival rates were calculated by the Kaplan-Meier method. Univariate analysis was performed with the log rank test and multivariate analysis was done using Cox's proportional hazard model. RESULT: The median follow-up time was 48 months. The overall survival rate was 55.9%, and the disease-free survival rate was 48.6%. Of 8 variables, two factors, visceral pleural invasion and lymphovascular invasion, were prognostic factors of disease-free survival (univariate analysis). Visceral pleural invasion was a significant prognostic factor in multivariate analysis, and overall survival in compared one or more variable such as visceral pleural invasion or, and lymphovascular invasion with the other variables. CONCLUSION: Visceral pleural invasion was identified as a poor prognostic factor and it may help select which patients will benefit from adjuvant chemotherapy in addition to more comprehensive follow-up.

The Change of Vascular Reactivity in Rat Thoracic Aorta 3 Days afterAcute Myocardial Infarction / 대한흉부외과학회지

BACKGROUND: The up-regulation of the nitric oxide (NO)-cGMP pathway might be involved in the change of vascular reactivity in rats 3 days after they suffer acute myocardial infarction. However, the underlying mechanism for this has not been clarified. MATERIAL AND METHOD: Acute myocardial infarction (AMI) was induced by occluding the left anterior descending coronary artery (LAD) for 30 min (Group AMI), whereas the sham-operated control rats were treated similarly without LAD occlusion (Group SHAM). The concentration-response relationships for phenylephrine (PE), KCl, acetylcholine (Ach) and sodium nitroprusside (SNP) were determined in the endothelium intact E(+) and endothelium denuded E(-) thoracic aortic rings from the rats 3 days after AMI or a SHAM operation. The concentration-response relationships of PE in the E(+) rings from the AMI rats were compared with those relationships in the rings pretreated with nitric oxide synthase (NOS) inhibitor N omega-nitro-L-arginine methyl ester (L-NAME) or the cyclooxygenase inhibitor indomethacin. The plasma nitrite/nitrate concentrations were checked via a Griess reaction. The cyclic GMP content in the thoracic aortic rings was measured by radioimmunoassay and the endothelial nitric oxide synthase (eNOS) mRNA expression was assessed by real time PCR. RESULT: The mean infarct size (%) in the rats with AMI was 21.3+/-0.62%. The heart rate and the systolic and diastolic blood pressure were not significantly changed in the AMI rats. The sensitivity of the contractile response to PE and KCl was significantly decreased in both the E(+) and E(-) aortic rings of the AMI group (p<0.05). L-NAME completely reversed these contractile responses whereas indomethacin did not (p<0.05). Moreover, the sensitivity of the relaxation response to Ach was also significantly decreased in the AMI group (p<0.05). The plasma nitrite and nitrate content (p<0.05), the basal cGMP content (p<0.05) and the eNOS mRNA expression (p=0.056) in the AMI rats were increased as compared with the SHAM group. CONCLUSION: Our findings indicate that the increased eNOS activity and the up-regulation of the NO-cGMP pathway can be attributed to the decreased contractile or relaxation response in the rat thoracic aorta 3 days after AMI.