[Surgical treatment for infective endocarditis].

OBJECTIVE: Surgery for infective endocarditis (IE) is technically demanding, especially the one for active IE. METHODS: Operations were performed in 21 patients with a mean age of 52.2 +/- 18.8 years. Fifteen patients were male, and 6 were female. There were 15 patients with active IE and 6 patients with healed IE. Isolated pathogens were Streptococcus in 8 cases, Staphylococcus in 3, and Enterococcus in 2. Two patients had prosthetic valve endocarditis. When the lesions affected the aortic valve, aortic valve replacement (AVR) was performed. When the lesions affected the mitral or tricuspid valves, valve repair was the treatment of choice. RESULTS: Six patients underwent AVR and 15 patients underwent a mitral valve operation (mitral valve repair in 13, replacement in 2). In 2 patients, mitral valve repair was changed to replacement, judged by intraoperative transesophageal echocardiogram. One patient underwent isolated tricuspid valve repair. Total survival and survival free of reoperation at 45 months was 95.2%. The grade of mitral regurgitation (MR) decreased from 3.7 +/- 0.1 to 0.2 +/- 0.1, and that of tricuspid valve regurgitation (TR) recovered from 3.5 +/- 0.5 to 1.0 +/- 1.0 at 21 +/- 15 months after the operation. CONCLUSIONS: Valve repair operations were useful in the mitral and tricuspid valve positions, even in the presence of active IE. Both mechanical valve and bioprosthesis showed good results after AVR for IE.

[Successful treatment applied to methicillin-resistant Staphylococcus aureus (MRSA) empyema after the operation for lung cancer; report of a case].

Empyema caused by methicillin-resistant Staphylococcus aureus (MRSA) remains an intractable infection producing high mortality. The authers report a case of MRSA empyema following video-assisted thoracic surgery (VATS) for lung cancer. The case was 73-year-old male with some risks such as pulmonary emphysema, decreased renal function, and previous history of brain infarction. He received wedge resection and the staple lines were wrapped with polyglycolic acid (PGA) felt. Ten days after the operation, he was complicated MRSA pyothorax. By thoracoscopic procedures under local anesthesia, fibrinopurulent tissues were cleaned and 3 of chest tubes were replaced. Intrathoracic infected space was cleaned with physiological saline solution. The patient made favorable progress and recovered. Further empyema has not been developed for 24 months. VATS under local anesthesia and irrigation technique was safe and so useful. Nowadays, PGA felt is often used to reinforce the staple lines of lung. PGA felt is an absorbable but artificial material. We have to care about infectious problems. However, we could control the MRSA pyothrax without removing the PGA felt.

[Usefulness of the thoracoscopic surgery under local anesthesia and irrigation for the patient with Bacillus cereus empyema; report of a case].

The case was 54-year-old male with some risks such as chronic heart failure, atrial fibrillation, and liver chirrhosis. He was admitted because of severe back pain and diagnosed as empyema by preoperative thoracentesis. By thoracoscopic procedures under local anesthesia, fibrinopurulent tissues were cleaned as much as possible and 3 of chest tubes were replaced. The final diagnosis was Bacillus cereus pyothorax by bacterial cultures of pleural effusion. Intrathoracic cavity was cleaned with physiological saline solution. The patient made favorable progress and recovered. Thoracoscopic surgery under local anesthesia with thoracic irrigation was so effective and safe methods to control the infection.

[Lung cancer with a cystic lesion formed by the check-valve mechanism].

A 55-year-old man was admitted to our hospital with a growing cystic lesion in the left middle field of the lung. After we diagnosed it as non-small cell lung cancer, we performed left upper lobectomy. A series of chest X-ray revealed that the cyst was formed by the check-valve mechanism due to the lung cancer, retrospectively. We should keep in mind the existence of lung cancer and other malignant tumors adjacent to cystic lesions.

[Cavitating pleomorphic carcinoma of the lung; report of a case].

We report a case of a previously healthy 76-year-old male with cavitating pleomorphic carcinoma of the lung. He was admitted because of an abnormal lung shadow on chest X-ray. Computed tomography (CT) showed a well-demarcated nodular shadow within thin-walled cavity in the right upper lobe. Because the lesion was revealed as adenocarcinoma by transbronchial lung biopsy, right upper lobectomy was performed. By histopathologic examination of the resected specimen, the nodule contained a component of spindle cell features and the cavity wall was composed of adenocarcinoma. The final diagnosis was pleomorphic carcinoma. Postoperative course has been uneventful for 12 months after surgery.

[Surgical therapy for impalpable small lung lesion; confirmation method by means of combining computed tomography (CT)-guided marking with soft X-ray radiography].

OBJECTIVE: We examined the usefulness of soft X-ray radiography of the specimen which was obtained by the lung wedge biopsy. PATIENTS AND METHODS: From September 2002 to September 2005, we entered the 10 cases (5 men and 5 women) which were consisted of 15 lesions. We performed lung wedge biopsy after computed tomography (CT)-guided lung marking, and then confirmed the lesion in the specimen by means of soft X-ray radiography. RESULTS: We could confirm impalpable small lung lesions in all cases. CONCLUSION: The confirmation method of impalpable small lung lesion that combined CT-guided lung marking with soft X-ray radiography was very useful.

[Acute empyema with intraoperative intractable air leaks in a child; report of a case].

We report a case of acute empyema with intraoperative intractable air leaks in a child. A 4-year-old girl was admitted with parapneumonic empyema by Staphylococcus aureus. Conventional conservative therapies such as antibiotics, chest tube drainage were failed. Then we performed dissection and debridement with video-assisted thoracoscopic surgery in fibrinopurulent phase of acute empyema. Intraoperative findings showed that the parietal pleura was very weak by Staphylococcus aureus pneumonia. Air leaks occurred,but pleural defects could not be closed by sutures and ligations. We could seal intractable air leaks to use fibrin glue soaked bioabsorbable polyglycolic acid felt sheet. Lung expansion promptly recovered and the patient was discharged on the 34th postoperative day without complications.

[Surgical resection for T4 lung cancer invading thoracic aorta].

The prognosis of the lung cancer patients with aortic invasion is thought to be very poor in general. Thoracic aorta resection and reconstruction was performed in 6 patients, aortic arch in 2, descending aorta in 4. An intraoperative and a postoperative major complication occurred in each 1 patient. Five patients survived more than 1 year after operation, and 1 of them has been living without relapse for more than 5 years. Pulmonary resection with the involved aorta can be done safely using cardiopulmonary bypass, with encouraging long-term survivals in patients without N2 or N3 nodal metastasis.

[Non-small cell lung cancer simultaneously metastatic to the brain treated by lobectomy and stereotactic irradiation].

We performed left upper lobectomy in 64-year-old man with non-small cell lung cancer (NSCLC) simultaneously metastatic to the brain. He was treated by stereotactic irradiation (STI) 2 months later after lobectomy. He has been doing well now without recurrence for 5 years after the operation. We think that STI and radical lobectomy are good alternatives for patients with NSCLC metastatic to the brain.

[Aortic dissection in elderly patients].

We performed 12 operations for aortic dissection in octogenarians from 1997 to 2004. Male : female = 1 : 11. Mean duration of follow-up is 33 +/- 19 months. As regards the etiology, acute type A aortic dissection was 8, chronic type A aortic dissection was 3 and chronic type B aortic dissection with distal arch aneurysm was 1. Total arch replacement was performed in 2 patients and hemiarch replacement in 10. In all patients with acute type A aortic dissection, hemiarch replacement was performed with the aid of selective cerebral perfusion or deep hypothermic circulatory arrest with retrograde cerebral perfusion. Postoperative respiratory failure was found in 1 patient, re-exploration for bleeding in 1, mediastinitis in 1 and temporary neurological dysfunction in 1. There was no hospital mortality. Two patients were died of respiratory failure 4 and 27 months after surgery. The results were acceptable. We recommend that age should not be the only determinant in deciding whether emergency operation should be performed in octogenarians.

[Usefulness of the eradication of Helicobacter pylori for the patient with idiopathic thrombocytopenic purpura and lung cancer: report of a case].

A 61-year-old female was admitted because of an abnormal lung shadow on chest X-ray. She had suffered from idiopathic thrombocytopenic purpura (ITP) for more than 7 years. Computed tomography (CT) revealed that an irregular shadow, about 2 cm in diameter, was located in the upper lobe of the right lung. After intravenous immunogrobulin injections for 5 days, a hematology test indicated increased platelet counts and we performed thoracoscopic surgery successfully without blood transfusions. However, 4 months after surgery, a hematology test indicated decreased platelet counts again. Thirteen months after the operation, gastrointestinal fiberscopic examination showed Helicobacter pylori infection. After the urea breath test, eradication therapy let to a recovery in platelet counts.

[Pulmonary hemangiopericytoma preoperatively diagnosed as mediastinal tumor; report of a case].

An asymptomatic 67-year-old female was admitted because of an abnormal shadow on chest X-ray. Computed tomography (CT) revealed that a well-marginated round mass with low density, about 4 cm in diameter, was located in the right hilum. The border was enhanced at contrast material-enhanced CT. Magnetic resonance imaging (MRI) [T2-weighted] showed the lesion as a high intensity tumor. Because of the extra-pleural sign on CT and normal results of broncho-fiberscopic (BFS) examination, mediastinal tumor was suspected. We performed thoracoscopic surgery and revealed that the tumor was in lung, not in mediastinum. Biopsy of the easy-bleeding tumor was performed. The histopathological diagnosis was hemangiopericytoma. There was no remarkable change for 1 years. Hemangiopericytomas should be considered in the differential diagnosis of well-marginated masses. Thoracoscopic surgery is the useful methods to diagnose the hemangiopericytoma.

Complete replacement of tracheal epithelia by the host promotes spontaneous acceptance of orthotopic tracheal allografts in rats.

BACKGROUND: Tracheal immunogenicity has been controversial. Although replacement of allotracheal epithelia by the host epithelia has been reported in rat orthotopic tracheal grafting, the immunological effect of epithelial replacement is still uncertain. METHODS: We performed orthotopic tracheal grafting of nine cartilage rings in the following groups: 1, Lewis --> Lewis (n = 30); 2, ACI --> DA (n = 25); 3, Lewis --> F344 (n = 23); 4-A, DA --> Lewis (n = 41); 4-B, DA --> Lewis with tacrolimus therapy (1 mg/kg/d for 10 days) starting from the day of the operation (n = 31); 4-C, retransplantation of DA allografts to secondary naive Lewis rats 10 or 15 days after primary grafting (n = 11); 4-D, DA --> Lewis with tacrolimus therapy starting from postoperative day 10 (n = 6). Survival times and histopathology were assessed. Epithelial replacement was evaluated by immunohistochemistry. RESULTS: All rats survived in groups 1, 2, and 3. Even in the fully histoincompatible group 4-A, survival ratio on day 120 was 15%. Epithelial replacement was in progress on day 10 in this group. However, all tacrolimus-treated rats died by day 54 and epithelial replacement did not occur on days 30 and 50 in group 4-B. In group 4-C, retransplantation after complete epithelial replacement increased the long-surviving rats. In group 4-D, all rats receiving tacrolimus therapy after complete epithelial replacement survived over 120 days. CONCLUSIONS: These results suggest that complete replacement of tracheal epithelia by the host promotes spontaneous acceptance of orthotopic tracheal allografts in rats.

Time course of gene expression after the injection of adenoviral vectors containing CTLA4IG gene.

INTRODUCTION: In vivo gene transfection using a recombinant adenoviral vector leads to diminished gene expression in a time-dependent manner that disappears within 4 weeks. CTLA4Ig blocks CD28-mediated costimulatory signal, and inhibits immune responses. We investigated the duration of transgene expression after administration of adenoviral vector containing CTLA4Ig gene (AdCTLA4Ig). METHODS: We injected 1 x 10(9) plaque forming units (pfu) of AdCTLA4Ig into rats (n = 7) via the tail vein. Thereafter, the blood samples were collected for assay of serum CTLA4Ig levels using enzyme-linked immunosorbent assay. RESULTS: The CTLA4Ig level reached the maximum (range, 65-86 microg/mL; average, 75 microg/mL) on days 3 to 5 after injection. Detectable levels of CTLA4Ig were observed up to 49 days. When we injected AdCTLA4Ig in combination with FTY720 administration, the maximum levels were higher and the detectable levels persisted longer. CONCLUSIONS: Because directly injected adenoviral transgene expression had been reported to disappear between 21 to 30 days, we conclude that AdCTLA4Ig inhibits the immune response and prolongs the transgene (CTLA4Ig gene) expression. Some additional immunosuppressants, like FTY720, may be useful to enhance AdCTLA4Ig effects.

[Extrapleural pneumonectomy after hyperthermo-chemotherapy for the lung cancer patients with malignant pleural effusion].

The prognosis of the lung cancer patients with malignant pleural effusion is extremely poor. Intrapleural perfusion hyperthermo-chemotherapy for the treatment of malignant pleural effusion was performed in 120 lung cancer patients and showed better prognosis than conventional treatment. After successful local control by hyperthermo-chemotherapy, extrapleural pneumonectomy was performed in 8 patients with clinical N 0 or N 1 and M 0 lung cancer. All patients survived for more than 1 year. The only 1 patient survived for more than 3 years and 3 months without recurrence. Almost all patients who died within 2 years had pathological n 2, carcinomatous pericarditis, cancer invasion beyond extrapleural space and so on. Extrapleural pneumonectomy after hyperthermo-chemotherapy can be a choice of surgical treatment if the n 2 disease, pericarditis, and extrapleural invasion of disseminated cancer cells should be excluded precisely.

[Total arch replacement with reconstruction of non-coronary sinus for acute type A aortic dissection after previous coronary artery bypass grafting; report of a case].

A 73-year-old man, who underwent coronary artery bypass grafting (CABG) 2 years previously, had suffered from acute type A aortic dissection with concomitant mild to moderate aortic regurgitation. A median resternotomy was performed. Arterial and venous cannulae were inserted into the femoral artery and vein to institute a cardiopulmonary bypass. The intimal tear was existed just above the sino-tubular junction. As the non-coronary sinus was involved in the dissection severely, it was resected in a scallop-shaped configuration. The aortic graft was tailored accordingly and anastomosis was performed in a curviliner fashion following the edge of scallop and the horizontally between the right and left coronary sinuses. Next, total arch replacement was performed using an aortic arch branched graft. Postoperative course was uneventful. Aortography revealed no aortic regurgitation and good patency of bypass graft.

[Thoracoscopically diagnosed multicentric Castleman disease; report of a case].

A 57-year-old female was admitted because of chest and back pain. Computed tomography (CT) revealed that many well-marginated lymph nodes were located in mediastinum and abdominal para-aortic area, especially in the right lower mediastinum. These lymph nodes were enhanced at contrast material-enhanced CT. We performed thoracoscopic surgery. The histopathologic diagnosis was multicentric Castleman disease (MCD). MCD should be considered in the differential diagnosis of multiple lymph nodes swelling with hyper globulinemia. Thoracoscopic surgery is the useful method to resect the lymph nodes and diagnose MCD.

[Thoracoscopically resected cystic mediastinal hemangioma; report of a case].

An asymptomatic 66-year-old female was admitted because of an abnormal shadow on chest X-ray. Computed tomography (CT) revealed that a well-marginated round mass with low density, about 3 cm in diameter, was located in the right anterior superior mediastinum. The border was partially enhanced at contrast material-enhanced CT. Magnetic resonance imaging (MRI) [T 2-weighted] showed the lesion as a high intensity tumor. We performed thoracoscopic surgery and resected the easy-bleeding tumor completely. The tumor was dark red in color and contained old blood. The histopathological diagnosis was hemangioma. There was no recurrence for 3 years. Hemangiomas should be considered in the differential diagnosis of well-marginated masses. Thoracoscopic surgery is the very useful methods to resect the mediastinal hemangioma.

[Air embolism following computed tomography-guided lung needle marking; report of a case].

We report air embolism following computed tomography (CT)-guided lung needle marking. A 55-year-old man was admitted to our hospital with left pulmonary tumor, characterized as ground glass opacity (GGO). To localize the tumor, lung needle marking under CT guidance was performed. Almost immediately, the patient experienced symptoms of cerebral arterial air embolism. CT revealed air in the left ventricle. About 2.5 hours later the symptoms and the air disappeared. Three days later a video-assisted thoracoscopic wedge resection was performed. The patient's postoperative course was uneventful, and he was discharged in good condition.

[Spinal cord protection and operative results of the thoracoabdominal aortic aneurysm].

The purpose of this study was to review retrospectively recent results in 75 patients undergoing thoracoabdominal aortic operations using the technique of distal aortic perfusion with segmental aortic clamping. Between July 1997 and November 2003, 46 males (61%) and 29 females (39%) were treated. The patients ranged in age from 26 to 82 (mean 63 +/- 13) years. Indications for surgery included dissecting thoracoabdominal aortic aneurysm (n = 28), atherosclerotic thoracoabdominal aortic aneurysm (n = 46), and traumatic aneurysm (n = 1). Emergency operation was performed in 8 (11%). The extent of aneurysm was Crawford type I in 12 patients, type II in 19, type III in 34, and type IV in 10. Profound hypothermic circulatory arrest was used in 3 patients and retrograde segmental clamping technique in 5. Cerebrospinal fluid drainage and naloxone hydrochloride administration were performed as adjunctive methods since February 2000. There were 6 (8%) in-hospital deaths. The overall incidence of postoperative paraplegia or paraparesis was 8% (6/75). Although the survival rate has improved, the problem of a complete prevention of ischemic spinal cord injury on the thoracoabdominal aortic operations remains unsolved. The multimodality approach is needed to reduce the risk of this devastating complication.