Extreme eccentric canal type pectus excavatum: morphological study and repair techniques.

OBJECTIVE: Extreme eccentric canal type pectus excavatum (Grand Canyon type, GC, Type 2A3), is a distinct morphological variation, characterized by an eccentric longitudinal canal. Due to the extent of depression and asymmetry, repair is often challenging with the minimally invasive technique. Following, we present its morphologic characteristics and evaluate repair techniques according to morphology type. METHODS: Extreme eccentric canal type pectus excavatum is an eccentric, long canal-like chest wall depression from the infra-clavicle to lower chest. Among 851 patients who underwent pectus excavatum repair from 1999 to 2007, 112 patients (13.2%) had the eccentric canal type. Morphologic type and repair techniques were evaluated; results were assessed by pectus indices (depression index (DI), asymmetry index (AI), and eccentricity index (EI)). RESULTS: Of the asymmetric cases, 31% (112/361) were the eccentric canal type. Female proportion (male to female ratio=2.3) was higher than in general pectus excavatum (4.1, p<0.05). Young female adults were more frequently affected (8/17, 47%, p<0.05). Repair techniques included asymmetric bar (n=97, 86.6%), seagull bar (n=53, 47.3%), crest compression (n=13, 11.6%), and parallel bar (n=79, 70.5 %) techniques. Pectus indices changes were: DI (pre 2.89 to post 1, p<0.01), AI (pre 1.11 to post 1.03, p<0.01), and EI (pre 1.69 to post 1, p<0.01). AI change represented asymmetric to symmetric correction. CONCLUSIONS: Extreme eccentric canal type pectus excavatum represents a distinctive morphology and requires special techniques for repair. Post-repair symmetry can be achieved by an asymmetric bar technique. Upper chest wall depression can be corrected by a parallel bar technique. Protruding ridge was relieved by a seagull bar or crest compression technique.

Scoliosis after pectus excavatum correction: does it improve or worsen?

OBJECTIVES: Scoliosis is associated with pectus excavatum. However, the change in the degree of scoliosis after pectus excavatum correction has not been clarified. This study examined how the correction of pectus excavatum influences the status of pre-existing scoliosis. METHODS: A total of 779 pectus excavatum patients operated between 2007 and 2011 using the pectus bar were retrospectively analysed. Preoperative severity and postoperative change of scoliosis in accordance with the severity of pectus excavatum were evaluated. Cobb angle, Haller index and sternal tilt degree were measured from pre- and postoperative whole-spine anteroposterior radiographs and chest computed tomography. RESULTS: Sixty-three (8%) patients had scoliosis (Cobb angle >10°). No significant correlation was noted between postoperative changes in Cobb angle, Haller index or sternal tilt angle. Preoperative severity of scoliosis showed a positive correlation with postoperative changes in Cobb angle ( r = 0.527, P < 0.001). In analyses between groups with mild and moderate scoliosis (Cobb angle <15° and >15°, respectively), the mean postoperative Cobb angle was decreased in mild scoliosis (-2.88°) but was increased in moderate scoliosis (3.86°; P < 0.001). Regarding the 'improvement' and 'aggravation' of scoliosis after pectus correction, preoperative severity of scoliosis was the only significant factor in univariable and multivariable analysis. CONCLUSIONS: Pectus excavatum repair using a pectus bar may improve scoliosis, but when the preoperative Cobb angle exceeds 15°, scoliosis may be aggravated. Therefore, pectus excavatum with concomitant moderate scoliosis requires extra caution during repair. This preliminary result suggests further investigation into the effect of chest cage remodelling on spine dynamics.

A non-randomized retrospective observational study on the subcutaneous esophageal reconstruction after esophagectomy: is it feasible in high-risk patients?

BACKGROUND: Esophageal reconstruction after esophagectomy is a complex procedure with high morbidity and mortality. Anastomotic leakage is more severe and frequent in patients with preoperative comorbidities and may present with septic conditions. Considering the possibility of an easier management of such cases, we evaluated the safety and feasibility of subcutaneous esophageal reconstruction in patients with high operative risks. METHODS: We performed a non-randomized retrospective observational study on the 75 (subcutaneous: 21, intrathoracic: 54) esophageal cancer patients who underwent esophageal reconstruction either through subcutaneous or intrathoracic route between January 2003 and February 2015. Preoperative data including the estimated reasons for the selection of the subcutaneous route were obtained from medical charts. Clinical outcomes were evaluated and compared between the two groups. RESULTS: The mean postoperative hospital stay was longer in the subcutaneous group than the overall group. Anastomotic leakage occurred more frequently in the subcutaneous group [10 (47.6%) vs. 7 (13%), P=0.004]. Three major leakages resulted in chronic cutaneous fistula, but were successfully treated by lower neck reconstruction using radial forearm fasciocutaneous free flap (RFFF). There was no in-hospital mortality in the subcutaneous group. CONCLUSIONS: Subcutaneous esophageal reconstruction in high-risk patients showed a higher rate of anastomotic leakage. However, easier correction without fatal septic conditions could be obtained by primary repair or flap reconstruction resulting in lower perioperative mortality. Therefore, esophageal reconstruction through the subcutaneous route is not recommended as a routine primary option. However, in highly selected patients with unfavorable preoperative comorbidities or intraoperative findings, especially those with poor blood supply to the graft, graft hematoma or edema, or gross tumor invasion to surrounding tissues, esophageal reconstruction through the subcutaneous route may carefully be considered as an alternative to the conventional surgical techniques.

Ventricular assist device implantation using a right thoracotomy.

Most patients needing implantation of a ventricular assist device (VAD) require repeated sternotomy; some after cardiac surgery, and others later for heart transplantation. The purpose of this study was to establish the right thoracotomy technique as an alternative for VAD implantation to reduce repeated sternotomy-related morbidity and mortality. We performed a right thoracotomy in animals, preclinical cadaver fitting tests, and a clinical case. A total of 20 various animals underwent right thoracotomy for implantation of bi-VAD (BVAD, n = 17) and left VAD (LVAD, n = 3). The right chest cavity was entered through the fourth intercostal space with partial resection of the fifth rib. There was no procedure-related morbidity or mortality, except for one calf with right anterior leg paralysis. Preclinical fitting tests were performed on 7 human cadavers to observe the anatomical feasibility of BVAD cannulation from the right side of the heart. In humans, the ascending aorta, interatrial groove, right atrium, and main pulmonary artery were identified as optimal cannula insertion sites for BVAD implantation. A patient with cardiogenic shock underwent a right thoracotomy for implantation of an external LVAD. Cardiac function recovered after 3 weeks, and the device was successfully explanted through a repeat right thoracotomy. In conclusion, a right thoracotomy can be an alternative method to the standard median sternotomy for patients who need repeated sternotomy because of previous cardiac surgery, transplantation at a later date, or those with mediastinal infections.

Management of descending necrotizing mediastinitis using minimally invasive video-assisted thoracoscopic surgery.

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis (DNM). However, the surgical techniques used for DNM treatment remain controversial. The purpose of this study was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) and cervical drainage for the management of DNM. Nine patients diagnosed with DNM were treated from May 2001 to April 2004. The mean age of the patients was 51.1+/-15.0 years. VATS and cervical drainage, including debridement and drainage of the mediastinum and pleura, were performed simultaneously. The mean postoperative hospital stay was 20.6+/-6.6 days. One patient (11%) died of sepsis and renal failure on the 15th postoperative day. Minimal mastication difficulty developed in 2 patients (22%). The mean postoperative follow-up period was 28.7+/-14.7(5 to 52) months. All the survivors are in good health with no recurrences. VATS was safe, effective, and a less invasive surgical option for the management of DNM and should be considered as a good alternative therapeutic modality.

Comparative Study of Cryostripping and Endovenous Laser Therapy for Varicose Veins: Mid-Term Results.

BACKGROUND: Conventional stripping is considered to be the standard procedure for great saphenous vein (GSV) varicosities, but many other alternative treatments such as cryostripping, endovenous laser therapy (EVLT), radio-frequency ablation, and ultrasound-guided foam sclerotherapy have been developed. Among them, both cryostripping and laser therapy have been reported to be less traumatic, with lower rates of complications and recurrences when compared to conventional stripping. To compare the efficacy of these treatments, we have analyzed and compared the mid-term clinical outcomes of cryostripping and EVLT. METHODS: Patients diagnosed with varicose veins of the GSV and treated with cryostripping or laser therapy between September 2008 and April 2013 were enrolled in this study. Duplex ultrasonography was used for the diagnosis and evaluation of varicosity and reflux, and the clinical-etiology-anatomy-pathophysiology classification was used to measure the clinical severity. The symptoms, Venous Clinical Severity Score (VCSS), recurrence rates, and complication rates of the cryostripping and laser therapy groups were analyzed and compared. RESULTS: A total of 68 patients were enrolled in this study. 32 patients were treated with cryostripping, and 36 patients were treated with laser therapy. The median follow-up period was 29.6 months. Recurrence was noted in three patients from the cryostripping group and in two patients from the EVLT group. There was no difference in the VCSS score, operative time, duration of hospital stay, and complication rate between the cryostripping group and the EVLT group. CONCLUSION: The mid-term clinical outcomes of cryostripping were not inferior to those of EVLT. Further, considering its cost-effectiveness, cryostripping seems to be a safe and feasible method for the treatment of varicose veins.

Transthoracic fine needle aspiration and core biopsy of pulmonary lesions. A study of 296 patients.

OBJECTIVE: To retrospectively investigate and compare the usefulness of transthoracic fine needle aspiration (FNA), core biopsy and a combination of the two in the diagnosis of pulmonary lesions. STUDY DESIGN: Two hundred ninety-six patients who had undergone FNA, core biopsy or both for lung lesions were divided into malignant and benign groups according to the final diagnoses, which were based on the cytologic and histopathologic findings combined with clinical features. In each group, the diagnostic usefulness of FNA, core biopsy and a combination of the two were evaluated by comparing the results of each with the final diagnoses. RESULTS: In the malignant group, FNA was diagnostically helpful in 188 of 205 patients (91.7%) and core biopsy in 158 of 180 patients (87.8%). The combination of the two methods improved the result to 172 of 178 patients (96.6%). The sensitivities were 94.6%, 88.3% and 97.2%, respectively, for each result. In the benign group, 71.1% (64/90), 70.1% (47/67) and 74.2% (49/66) of cases received specific or nonspecific diagnoses by FNA, core biopsy and their combination, respectively. The rates of specific diagnoses were 20.1%, 21.0% and 31.8%, respectively. CONCLUSION: The combination of FNA and core biopsy markedly improved the diagnostic yields in the malignant group and, to a lesser degree, also in the benign group.

Acute descending aortic dissection associated with coarctation in adult.

A 44-year-old man with congenital aortic coarctation experienced acute dissection that crossed the coarctation and extended to both iliac arteries. The primary entry of the dissection was proximal to the coarctation segment, just below the origin of the left subclavian artery. Surgical procedures involved resection of the diseased segment including the coarctation, and graft interposition.

Optimal timing of thoracoscopic drainage and decortication for empyema.

BACKGROUND: Although video-assisted thoracic surgery (VATS) pleural drainage and decortication have been proven to be effective treatments in the early stages of empyema, the optimal timing of VATS is still not clear. To assess the effectiveness of early VATS drainage and decortication, we reviewed the records of patients who underwent VATS and open decortication for empyema. METHODS: One hundred twenty-eight patients with empyema were treated with VATS and open decortication over 8 years at Korea University Anam Hospital. The VATS patients (120 patients) were divided into 3 groups based on the interval between the onset of chest symptoms and the time of operation (group 1: <2 weeks; group 2: 2 to 4 weeks; group 3: >4 weeks). Additional 8 open decortication patients with symptom durations greater than 4 weeks were compared with group 3 patients. RESULTS: Groups 1 and 2 showed shorter chest tube duration, postoperative hospital stay, surgical procedure time, and fewer prolonged air leaks than group 3. No significant difference was noted between groups 1 and 2; and no difference was noted in the length of postoperative intensive care unit stays or the reintervention and reoperation rates among the 3 groups. In chronic empyema patients, group 3 showed shorter chest tube duration than the open decortication group. CONCLUSIONS: Patients with symptom durations of less than 4 weeks showed better early results than those with symptom durations greater than 4 weeks. Thus, symptom duration can be considered a reliable preoperative factor in deciding the surgical management of empyema or cases involving loculated pleural effusion.

Resection of Intrapericardial Schwannoma Co-Existing with Thymic Follicular Hyperplasia through Sternotomy without Cardiopulmonary Bypass.

A 35-year-old man was admitted to Korea University Anam Hospital for evaluation of intermittent chest pain. Computed tomography of the chest showed enlargement of a previously identified anterior mediastinal mass and also a well-defined, circumscribed mass in the subcarinal area, surrounded by the roof of the left atrium, right pulmonary artery, and the carina. Complete resection of the intrapericardial tumor was performed through median sternotomy without cardiopulmonary bypass. Pathologic examination identified the tumor as schwannoma, of an ancient type, diffusely positive for the S-100 antigen. Unlike other reported cases, grossly, the tumor did not seem to be involved with any nerve.

Is There a Role for a Needle Thoracoscopic Pleural Biopsy under Local Anesthesia for Pleural Effusions?

BACKGROUND: A closed pleural biopsy is commonly performed for diagnosing patients exhibiting pleural effusion if prior thoracentesis is not diagnostic. However, the diagnostic yield of such biopsies is unsatisfactory. Instead, a thoracoscopic pleural biopsy is more useful and less painful. METHODS: We compared the diagnostic yield of needle thoracoscopic pleural biopsy performed under local anesthesia with that of closed pleural biopsy. Sixty-seven patients with pleural effusion were randomized into groups A and B. Group A patients were subjected to closed pleural biopsies, and group B patients were subjected to pleural biopsies performed using needle thoracoscopy under local anesthesia. RESULTS: The diagnostic yields and complication rates of the two groups were compared. The diagnostic yield was 55.6% in group A and 93.5% in group B (p<0.05). Procedure-related complications developed in seven group A patients but not in any group B patients. Of the seven complications, five were pneumothorax and two were vasovagal syncope. CONCLUSION: Needle thoracoscopic pleural biopsy under local anesthesia is a simple and safe procedure that has a high diagnostic yield. This procedure is recommended as a useful diagnostic modality if prior thoracentesis is non-diagnostic.

Porcine dermal collagen (permacol) for sternal reconstruction.

In chest wall reconstruction after wide chest wall resection, the use of a musculocutaneous flap or prosthetic materials is inevitable for maintaining thoracic movement and a closed pleural cavity. We report a case of a 63-year-old male with a large invasive thymic carcinoma in the anterior mediastinum. The mass measured 6.8 cm and involved the sternum, left side of the parasternal area, ribs, and intercostal muscles. The patient underwent subtotal sternectomy, radical thymectomy, and reconstruction with biological mesh (Permacol). Successful chest wall reconstruction without any other complications was achieved, demonstrating the effectiveness of Permacol.

Surgical resection of adenocarcinoma arising from an accessory cardiac bronchus.

A 62-year-old woman was referred to our hospital for evaluation of hemoptysis. Chest computed tomography demonstrated an accessory cardiac bronchus (ACB) arising from the carina with a well-defined mass approximately 3 cm in size. Fiberoptic bronchoscopy also revealed the presence of an ACB arising from the carina. We performed mass excision and en bloc resection of portions of the pericardium. Pathologic examination revealed that the tumor was an adenocarcinoma arising from an ACB.

Early results of cryosurgery in varicose veins in Korea: safety and feasibility.

BACKGROUND: Cryosurgery was recently introduced as a treatment for varicose veins in the lower extremities. Cryosurgery with freezing probes can be used to remove the great saphenous vein (GSV) via an inguinal incision alone. The aim of this study was to assess early outcomes and the feasibility of cryosurgery for varicose veins. MATERIALS AND METHODS: Forty patients were enrolled in the present study from March 2009 to July 2010. All patients underwent careful physical examinations, and their GSV reflux was demonstrated by duplex ultrasonography. Clinical severity was measured according to the clinical-etiology-anatomy-pathophysiology (CEAP) classification. The impaired GSVs were removed with rigid cryoprobes after freezing. Patients had follow-up appointments at 1 week, 1 month, 3 months, and 6 months after surgery. Sclerotherapy was performed during follow-up on an outpatient basis as needed. RESULTS: A total of 19 men and 21 women were enrolled. The mean follow-up duration was 3.4 months (range, 1 to 12 months). The clinical severity ranged from CEAP 2 to CEAP 6a. Thirty-eight patients underwent concomitant phlebectomy during surgery. No recurrences were reported during follow-up. There were three cases of minor complications. Two patients had paresthesia, and one had thrombophlebitis. CONCLUSION: Using cryosurgery techniques to treat varicose veins, the complication rates were minimal and outcomes were comparable to those of previous reports. This procedure is a safe and feasible treatment modality for varicose veins.

Hinge reinforcement plate for adult pectus excavatum repair: a novel tool for the prevention of intercostal muscle strip.

Adult pectus excavatum has been a challenge to repair by the conventional Nuss technique. The hinge point, the pivot for pectus bar rotation, is not strong enough to sustain the heavy adult chest. To prevent intercostal muscle strip at the hinge, we developed a hinge reinforcement plate. The hinge plate is a metal strip with a concave cradle designed to support the pectus bar at the hinge points (intercostal space entrance point). One hundred and two adolescent and adult patients (≥ 15 years old) who underwent pectus repair with our modified technique using pectus bars between April 2008 and March 2010 were analyzed. There were 27 patients repaired with the hinge plate (H group) and 75 patients without the hinge plate (N group). The mean age was 19.4 years (15-35 years). The degree of chest wall depression and asymmetry was not different between the groups (P > 0.05). There were three cases of bar displacement in the N group (4%), but no bar displacement (0%) in H group. Our results suggest that the hinge plate is effective in preventing an intercostal muscle strip at the hinge points and may play a crucial role in expanding the minimally-invasive technique to adult pectus excavatum.

Endoscopic cryosurgical resection of pulmonary hamartoma with flexible bronchoscopy.

Pulmonary hamartoma is one of the most common benign lung tumors. Well-known conventional methods of treatment for lung hamartomas include VATS enucleation or wedge resection, bronchoplasty, and others. Here we present a case of endobronchial hamartoma that was successfully treated with cryosurgery by flexible bronchoscopy.

Gastropericardial fistula-induced pyopneumopericardium after esophagectomy with esophagogastrectomy.

Gastropericardial fistula is an acquired disorder presenting as an abnormal communication between the stomach and the pericardium, with a rare incidence and extremely high mortality rate. We recently experienced a case of life-threatening gastropericardial fistula occurring as an unusual complication after an esophagectomy with an esophagogastrostomy for esophageal cancer treatment. A 68-year-old man with a history of esophagectomy and esophagogastrostomy using the gastric pedicle for the esophageal cancer 13 years ago, visited the hospital with a complaint of dyspnea for 3 days. Chest roentgenogram, computed tomographic scan, and endoscopy showed a pneumopericardium and huge ulcer with central perforation in the posterior wall of the gastric pedicle.

Changes in RBC deformability and oxygen-delivering ability in cold blood cardioplegia.

PURPOSE: The advantages of blood cardioplegia, which is used for myocardial protection during open heart surgeries, include superior oxygen-carrying capacities, better osmotic properties, and the presence of more antioxidants than a crystalloid counterpart. Although, hyperkalemic organ-preserving solutions for transplantation surgeries are known to decrease RBC deformability essential for tissue perfusion, only few studies have addressed the changes in RBC deformability after exposure to cardioplegic additives. The purpose of this study was to measure deformability and oxygen-delivery capacities in various blood cardioplegic solutions. METHODS: Blood from eight healthy volunteers was used. Each sample (100 ml) was divided into 5 groups of 16 ml, and cardioplegia solutions were added (group NS; blood + normal saline, group K; blood + KCl, group D; blood + KCl + diltiazem, group A: blood + KCl + adenosine, group E: blood + KCl + neutrophil elastase inhibitor [Sivelestat]). All samples were incubated at a temperature of 8°C for 10 minutes. Deformability, NO level, 2,3-DPG, and ATP were measured. RESULTS: There was no statistically significant difference (p = 0.92) in deformability between the groups. The NO levels were not significantly different (p = 0.86). The 2,3-DPG (p = 0.27) and ATP levels (p = 0.40) were not significantly different. CONCLUSIONS: The deformability and oxygen carrying functions of RBCs did not show a significant difference according to various components of cold blood cardioplegia during 10 minutes of incubation.

Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patient-specific approach.

OBJECTIVE: Minimally invasive repair of pectus excavatum, introduced by Nuss in 1998, has undergone a serious learning curve because of a lack of understanding on morphologies and repair techniques. To summarize the current status of minimally invasive repair of pectus excavatum, we reviewed and appraised our 10-year experience with a novel approach, a morphology-tailored technique, including diverse bar shaping, bar fixation, and techniques for adults. METHODS: We analyzed the data of 1170 consecutive patients with pectus excavatum who underwent minimally invasive repair between August 1999 and September 2008. All pectus repairs were performed by the primary author (H.J.P.) with our modified technique. RESULTS: The mean age was 10.3 years (range, 16 months to 51 years). There were 331 adult patients (>15 years) (28.3%). A total of 576 patients (49.2%) had bar removal after a mean of 2.5 years (range, 10 days to 7 years). The asymmetry index change (1.10-1.02, P < .001) demonstrated post-repair symmetry. Complication rates decreased through the 3 time periods (1999-2002 [n = 335]; 2003-2005 [n = 441]; 2006-2008 [n = 394]) as follows: pneumothorax rate (7.5% vs 4.3% vs 0.8%; P < .001) and bar displacement rate (3.8% vs 2.3% vs 0.5%; P = .002). Reoperation rate also decreased (4.8% vs 2.5% vs 0.8%; P = .002). Satisfaction outcomes were excellent in 92.7%, good in 5.9%, and fair in 1.4% of patients. After bar removal, 3 patients (0.6%) had minor recurrences. CONCLUSION: Minimally invasive repair of pectus excavatum based on a novel morphology-tailored, patient-specific approach is effective for quality repair of the full spectrum of pectus excavatum, including asymmetry and adult patients. Continuous technical refinements have significantly decreased the complication rates and postoperative morbidity.

Measurement of hemodynamic energy at different vessels in an adult swine model.

Extra hemodynamic energy is one of the major benefits of pulsatile flow, improving blood flow to vital organs. But most (80%) of the hemodynamic energy generated from pulsatile flow is damped by the extracorporeal circuit. Most models devised to minimize hemodynamic energy loss have been in vitro pediatric models. The purpose of this study was to measure hemodynamic energy in different vessels of different organs with an in vivo adult swine model. An extracorporeal circuit was constructed for seven Yorkshire swine using a pulsatile pump (Twin-Pulse Life Support). The mean arterial pressure (MAP), energy equivalent pressure (EEP), and surplus hemodynamic energy (SHE) at the renal artery, carotid artery, aortic cannula site, and postoxygenator site were measured simultaneously before starting the pump and at the pump rates of 25, 35, and 45 bpm. The MAP of the renal or carotid artery was 40.0%-51.2% of the postoxygenator site. The EEP and SHE of both arteries were 11.6%-13.0% and 5.5%-7.4% of the postoxygenator site, respectively. The MAP and EEP of both arteries after starting the pump were lower than at baseline. The SHE of the renal artery after starting the pump was significantly higher than at baseline. The SHE of the carotid artery increased substantially after starting the pump although not statistically significantly. There was a significant hemodynamic energy loss in both arterial sites compared with the postoxygenator site. Also, a difference in hemodynamic energy loss was observed in vessel-to-vessel or vessel-to-circuit site comparison. This difference creates a bias in studying pulsatility and its effects. Therefore, the measurement method of hemodynamic energy must be standardized and the measurement site clarified to yield accurate study results.