New bullae formation in the staple line increases the risk of recurrent pneumothorax following video-assisted thoracoscopic surgery bullectomy for primary spontaneous pneumothorax.

BACKGROUND: The study aimed to investigate the association between the recurrence of pneumothorax following video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax (PSP) and the formation of new bullae. METHODS: This retrospective review examined patients who underwent VATS for PSP between April 2009 and December 2014. Of the 415 operated lungs, high-resolution computed tomography (HRCT) scans of 85 were analyzed. RESULTS: Of the 85 HRCT scans examined, 21 (24.7%) were diagnosed with recurrent pneumothorax and 60 new bullae were found. In total, 39 new bullae were located in the staple line, 38 were at other sites far from the staplers, and 17 were concurrent in the stapling and non-stapling areas. The group with new bullae in staple line exhibited significantly higher recurrence rate following VATS than the groups with no new bullae in the staple line (P=0.000, log-rank test). Cox regression analysis revealed that new bullae formation in the staple line [hazard ratio (HR), 26.664; P=0.003] and the volume of a resected pathology specimen (HR, 1.032; P=0.020) were independent risk factors for pneumothorax recurrence. CONCLUSIONS: New bullae formation in the staple line increases the risk of recurrent pneumothorax following VATS. Thus, the current concept of VATS bullectomy-resect with sufficient margin-warrants reconsideration.

Influence of lung resection volume on risk of primary spontaneous pneumothorax recurrence.

BACKGROUND: Thoracoscopic stapled bullectomy is a popular procedure for the treatment of primary spontaneous pneumothorax (PSP) that has a relatively high postoperative recurrence rate. One reason for PSP recurrence is the formation of a new bulla around the staple line. We hypothesized that different resected specimen volumes might cause differences in staple line tension. In this study, we analyzed the relationship between postoperative pneumothorax recurrence and resected lung volume. METHODS: Between April, 2009 and December 2013, 360 cases which underwent video-assisted thoracoscopic surgery (VATS) for PSP were selected. Recurrence after VATS was examined by electronic medical records and telephone survey. Resected volume and vertical area of specimen were calculated with the size of pathologic specimen. RESULTS: A mean follow up period was 44.5±24.4 months and recurrence rate was 11.1% (40/360). Large volume of resected specimen (≥16 cm3) (P=0.027 by the log-rank test) and larger vertical area of resected specimen (≥2.0 cm2) (P=0.003 by the log-rank test) showed significantly high recurrence rate. Cox regression analysis demonstrated that age [hazard ratio (HR), 0.083, P=0.006], vertical section area of resected specimen (HR, 1.239, P=0.020) and volume of resected pathology specimen (HR, 1.039, P=0.009) were independent risk factors of recurrence. CONCLUSIONS: Bulky resection during VATS for PSP increases the risk of recurrence. Large volume and vertical area of resected specimen are associated with greater tension in stapling line. Avoidance of wide resection and the firing of stapler after full collapse of lung are recommended for reducing the pneumothorax recurrence after VATS.

New protocol for a reversal operation in endoscopic thoracic sympathetic clamping: pulling back the suture sling linked to the clip under local anesthesia.

Endoscopic thoracic sympathetic clamping (ETC) has widely been used for treating the patients with primary hyperhidrosis, as it offers the potential of reversal operation (unclipping) under general anesthesia (GA) when severe reflex sweating would occur. However, we modified ETC to unclip under local anesthesia. From March 2002 to January 2005, we performed ETC in 87 patients with primary hyperhidrosis. From September 2002 on, the suture sling which was made with a 3-0 propylphylene suture was additionally placed between the endoclip and the subcutaneous tissue of the thoracoport. When unclipping was needed, the endoclip was removed by being pulled back under portable fluoroscopy. Four of 53 patients (7.5%) who underwent ETC alone underwent unclipping under GA. By contrast, unclipping was successfully performed under local anesthesia in 5 of 34 patients (14.7%) who underwent the modified ETC. ETC will be more effective operation if it is modified concomitantly with the suture sling; otherwise the reversal operation will need GA for the unclipping.

Disseminated intravascular coagulopathy caused by type II endoleak after endovascular aneurysm repair in severe aortic stenosis.

A 72-year-old man with severe aortic stenosis (AS) presented with a type II endoleak after endovascular aneurysm repair (EVAR). Laboratory findings were consistent with disseminated intravascular coagulopathy (DIC) with thrombocytopenia. The platelet count increased slightly after aortic valve replacement but fully recovered with the reversal of DIC after surgical repair of the type II endoleak.

Low grade myxofibrosarcoma in the right ventricle presenting as pulmonary thromboembolism.

We report an unusual malignant cardiac neoplasm that initially presented as pulmonary thromboembolism in a 78-year-old male. Despite anticoagulation, the pulmonary artery lesion progressed and a mass-like lesion developed in the right ventricular outflow tract. Venoarterial extracorporeal membrane oxygenation was applied before surgery due to the presence of severe right-side heart failure with pulmonary hypertension. A round mass was found in the right ventricle and separate lobulated masses were found in both pulmonary arteries, and these were consistent with low-grade myxofibrosarcoma.

Costal exostoses as an unusual cause of spontaneous hemothorax.

A 20-year-old male presented with chest pain lasting several days. A radiologic examination revealed pleural effusion in the right hemithorax. Video-assisted thoracoscopic surgery demonstrated a bleeding focus at the diaphragm caused by injury due to a costal exostosis.

Congenital tracheobiliary fistula in an adolescent patient.

Congenital tracheobiliary fistula is a rare malformation that allows communication between the respiratory system and hepatobiliary tract. We describe a male adolescent patient who was admitted with a destroyed lung caused by repetitive bile pneumonitis with a congenital tracheobiliary fistula. Left pneumonectomy was performed, and the fistula tract was successfully divided.

Nodular fasciitis on chest wall in a teenager: a case report and review of the literature.

We report the case of a 16-year-old boy with a rapid growing mass on his left anterior chest wall. The mass was completely resected, and pathological examination confirmed nodular fasciitis. Benign chest tumors rarely occur in childhood. Nodular fasciitis is a benign proliferation of myofibroblast that is often mimicked by a sarcoma of the soft tissue. Physicians should consider the possibility of nodular fasciitis in chest wall tumors in the pediatric population.

Delayed-onset hypovolemic shock after the Nuss procedure for pectus excavatum.

The Nuss procedure, which is a minimally invasive approach for treating pectus excavatum, has better functional and cosmetic outcomes than other invasive procedures. Cardiac perforation is the most serious complication and several methods for the prevention of intraoperative events has been developed. Although most cardiac injuries are detected in the operating room, in the case described herein the patient experienced sudden hypovolemic shock during the postoperative recovery period. This indicates that special caution is mandatory even after successful execution of the Nuss procedure.

Risk factors for the development of reexpansion pulmonary edema in patients with spontaneous pneumothorax.

BACKGROUND: Reexpansion pulmonary edema (REPE) is known as a rare and fatal complication after tube thoracostomy. OBJECTIVES: We investigated the risk factors for the development of REPE in patients with spontaneous pneumothorax. METHODS: We selected patients who were diagnosed with spontaneous pneumothorax and were initially treated with tube thoracostomy between August 1, 2003 and December 31, 2011. The patients' electronic medical records, including operative notes and chest x-ray and computed tomography scans, were reviewed. RESULTS: REPE developed in 49 of the 306 patients (16.0%). REPE was more common in patients with diabetes (14.3% vs 3.9%, P=0.004) or tension pneumothorax (46.8% vs 16.2%, P=0.000). The pneumothorax was larger in patients with REPE than without REPE (57.0±16.0% vs 34.2±17.6%, P=0.000), and the incidence of REPE increased with the size of pneumothorax. On multivariate analysis, diabetes mellitus [(odds ratio (OR)=9.93, P=0.003), and the size of pneumothorax (OR=1.07, P=0.000) were independent risk factors of REPE. CONCLUSIONS: The presence of diabetes increases the risk of REPE development in patients with spontaneous pneumothorax. The risk of REPE also increases significantly with the size of pneumothorax.

Tension pneumothorax, is it a really life-threatening condition?

BACKGROUND: Tension pneumothorax is a life-threatening occurrence that is infrequently the consequence of spontaneous pneumothorax. The aim of this study was to identify the risk factors for the development of tension pneumothorax and its effect on clinical outcomes. METHODS: We reviewed patients who were admitted with spontaneous pneumothorax between August 1, 2003 and December 31, 2011. Electronic medical records and the radiological findings were reviewed with chest x-ray and high-resolution computed tomography scans that were retrieved from the Picture Archiving Communication System. RESULTS: Out of the 370 patients included in this study, tension pneumothorax developed in 60 (16.2%). The bullae were larger in patients with tension pneumothorax than in those without (23.8 ± 16.2 mm vs 16.1 ± 19.1 mm; P = 0.007). In addition, the incidence of tension pneumothorax increased with the lung bulla size. Fibrotic adhesion was more prevalent in the tension pneumothorax group than in that without (P = 0.000). The bullae were large in patients with fibrotic adhesion than in those without adhesion (35.0 ± 22.3 mm vs 10.4 ± 11.5 mm; P = 0.000). On multivariate analysis, the size of bullae (odds ratio (OR) = 1.03, P = 0.001) and fibrotic adhesion (OR = 10.76, P = 0.000) were risk factors of tension pneumothorax. Hospital mortality was 3.3% in the tension pneumothorax group and it was not significantly different from those patients without tension pneunothorax (P = 0.252). CONCLUSIONS: Tension pneumothorax is not uncommon, but clinically fatal tension pneumothorax is extremely rare. The size of the lung bullae and fibrotic adhesion contributes to the development of tension pneumothorax.

Adventitial fibroblast abormality in thoracic aortic aneurysms and aortic dissections.

BACKGROUND: Development of thoracic aortic aneurysms and aortic dissections (TAAD) is attributed to unbearable wall tension superimposed on defective aortic wall integrity and impaired aortic repair mechanisms. Central to this repair mechanisms are well-balanced and adequately functional cellular components of the aortic wall, including endothelial cells, smooth muscle cells (SMCs), inflammatory cells, and adventitial fibroblasts. Adventitial fibroblasts naturally produce aortic extracellular matrix (ECM), and, when aortic wall is injured, they can be transformed into SMCs, which in turn are involved in aortic remodeling. We postulated the hypothesis that adventitial fibroblasts in patients with TAAD may have defects in ECM production and SMC transformation. MATERIALS AND METHODS: Adventitial fibroblasts were procured from the adventitial layer of fresh aortic tissues of patients with TAAD (Group I) and of multi-organ donors (Group II), and 4-passage cell culture was performed prior to the experiment. To assess ECM production, cells were treated with TNF-α (50 pM) and the expression of MMP-2 / MMP-3 was analyzed using western blot technique. To assess SMC transformation capacity, cells were treated with TGF-ß1 and expression of SM α-actin, SM-MHC, Ki-67 and SM calponin was evaluated using western blot technique. Fibroblasts were then treated with TGF-ß1 (10 pM) for up to 10 days with TGF-ß1 supplementation every 2 days, and the proportion of transformed SMC in the cell line was measured using immunofluorescence assay for fibroblast surface antigen every 2 days. RESULTS: MMP-3 expression was significantly lower in group I than in group II. TGF-ß1-stimulated adventitial fibroblasts in group I expressed less SM α-actin, SM-MHC, and Ki-67 than in group II. SM-calponin expression was not different between the two groups. Presence of fibroblast was observed on immunofluorescence assay after more than 6 days of TGF-ß1 treatment in group I, while most fibroblasts were transformed to SMC within 4 days in group II. CONCLUSION: ECM production and SMC transformation are compromised in adventitial fibroblasts from patients with TAAD. This result suggests that functional restoration of adventitial fibroblasts could well be a novel approach for the prevention and treatment of TAAD.

Identification of genomic aberrations by array comparative genomic hybridization in patients with aortic dissections.

BACKGROUND: The aim of the present study was to identify chromosomal loci that contribute to the pathogenesis of aortic dissection (AD) in a Korean population using array comparative genomic hybridization (CGH) and to confirm the results using real-time polymerase chain reaction (PCR). MATERIALS AND METHODS: Eighteen patients with ADs were enrolled in this study. Genomic DNA was extracted from individual blood samples, and array CGH analyses were performed. Four corresponding genes with obvious genomic changes were analyzed using real-time PCR in order to assess the level of genomic imbalance identified by array CGH. RESULTS: Genomic gains were most frequently detected at 8q24.3 (56%), followed by regions 7q35, 11q12.2, and 15q25.2 (50%). Genomic losses were most frequently observed at 4q35.2 (56%). Real-time PCR confirmed the results of the array CGH studies of the COL6A2, DGCR14, PCSK6, and SDHA genes. CONCLUSION: This is the first study to identify candidate regions by array CGH in patients with ADs. The identification of genes that may predispose an individual to AD may lead to a better understanding of the mechanism of AD formation. Further multicenter studies comparing cohorts of patients of different ethnicities are warranted.

Delayed primary repair of perforated epiphrenic diverticulum.

A 68-yr-old man complaining of sudden, postprandial chest pain visited the emergency room. His symptom had been aggravated during the preceding two days. Upper gastrointestinal contrast study with gastrographin showed leakage of dye from the epiphrenic diverticulum in the lower third of the esophagus. The primary repair was urgently carried out. Upper gastrointestinal contrast study 14 days after operation revealed an esophageal leakage which was small and confined. The patient was managed with conservative treatments such as intravenous hyperalimentation and broad-spectrum antibiotics. Forty-two days after the operation, a gastrographin swallow study showed the absence of leaks. This is the first reported case of a perforated epiphrenic esophageal diverticulum repaired by delayed primary repair in Korea.