Simultaneous lateral and subxiphoid access methods for safe and accurate resection of a superior vena cava aneurysm: A case report.

BACKGROUND: Superior vena cava (SVC) aneurysms are a relatively uncommon disease that has not been widely reported. The conventional surgical approach for treating SVC aneurysms includes open thoracotomy and mid-sternotomy. However, in this case, the aneurysm could be safely resected by thoracoscopic simultaneous lateral and subxiphoid access methods. CASE SUMMARY: A 58-year-old male presented with intermittent chest pain and persistent discomfort in the chest area. A chest computed tomography scan revealed a 6.2 cm aneurysm in the left innominate vein and SVC junction. For surgical resection, simultaneous lateral and subxiphoid access were planned to achieve optimal proximal and distal aneurysm control. The approach site was 1 cm below the xiphoid process, the fifth mid-axillary line and the seventh anterior axillary line on the right side. The aneurysm was resected using a stapler. The patient was discharged on the third day after chest tube removal on the second postoperative day with no particular issues. CONCLUSION: Aneurysms located within the mediastinum can be accessed through thoracoscopic approach without open surgery and safely resected using vascular staples.

A Comparative Study of a Sternum-Sparing Procedure and Clamshell Incision in Bilateral Lung Transplantation.

PURPOSE: Clamshell incision offers excellent exposure and access to the pleural spaces and is a standard incision for lung transplantation. However, due to its high sternal complication rate, the clamshell incision is considered a procedure that requires improvement. In this study, we aimed to investigate the outcomes of transverse sternotomy with clamshell incision in comparison to sternum-sparing bilateral anterolateral thoracotomy (BAT). MATERIALS AND METHODS: In total, 134 bilateral sequential lung transplants were performed from May 2013 to June 2022. The clamshell incision was used between May 2013 and December 2017, and the BAT was introduced in January 2018. Thirty-four patients underwent clamshell surgery, and 100 patients underwent BAT. We retrospectively compared patient characteristics and perioperative and postoperative outcomes between the two groups. RESULTS: The clamshell group required an operation time of 745.18±101.76 min, which was significantly longer than that of the BAT group at 669.90±134.09 min (p=0.003). The mechanical ventilation period after surgery was 17.26±16.04 days in the clamshell group, significantly longer than the 11.35±12.42 days in the BAT group (p=0.028). Intensive care unit stay was also significantly longer in the clamshell group (21.54±15.23 days vs. 15.03±14.28 days; p=0.033). In-hospital mortality rates were 26.5% in the clamshell group and 22.0% in the BAT group. CONCLUSION: Less-invasive lung transplantation via sternum-sparing BAT is a safe procedure with low morbidity and favorable outcomes. Preventing sternal instability enables more stable breathing after surgery, earlier weaning from mechanical ventilation, and faster recovery to routine activities.

Indications for Lung Transplantation and Patient Selection.

Globally, thousands of patients undergo lung transplantation owing to end-stage lung disease each year. As lung transplantation evolves, recommendations and indications are constantly being updated. In 2021, the International Society for Heart and Lung Transplantation published a new consensus document for selecting candidates for lung transplantation. However, it is still difficult to determine appropriate candidates for lung transplantation among patients with complex medical conditions and various diseases. Therefore, it is necessary to analyze each patient's overall situation and medical condition from various perspectives, and ongoing efforts to optimize the analysis will be necessary. The purpose of this study is to review the extant literature and discuss recent updates.

Electrophysiological Monitoring of Neurochemical-Based Neural Signal Transmission in a Human Brain-Spinal Cord Assembloid.

Combining human brain organoids holds great potential in recapitulating the human brain's histological features and modeling neural disorders. However, current combined-brain organoid models focus on the internal interactions between different brain regions. In this study, we develop an engineered brain-spinal cord assembloid (eBSA) by coculturing cerebral organoids (COs) and motor neuron spheroids (MNSs). By connecting COs and MNSs, we generate a terminal for signal transfer from the brain to the whole body by mimicking the brain-spinal cord connection. After the formation of COs from human induced pluripotent stem cells and MNSs from human neural stem cells, MNSs are prepatterned into specific CO regions and assembled to form an eBSA. Caffeine serves as a neurochemical model to demonstrate neural signal transmission. When the MNSs in the eBSA contact the multielectrode array, the eBSA successfully shows an increased neural spiking speed on the motor neuron region by caffeine treatment, which means that neural stimulation signals transfer from the COs to MNSs. The neural stimulation effects of caffeine are tested on the MNSs only to prove the eBSA system's neural signal transmission, and there were no stimulus effects. Our results demonstrate that the eBSA system can monitor a caffeine-mediated excitatory signal as an output signal from the brain to the spinal cord. We believe that the eBSA system can be utilized as a screening platform to validate the stimulus signal transfer by neurochemicals. In addition, the accumulation of understanding of the neural signal transfer from CNS to PNS will provide better knowledge for controlling muscle actuators with the nervous system.

Morphological Adaptation after Bilateral Lung Transplantation in a Patient with Kartagener Syndrome: A Case Report.

Kartagener syndrome (KS) is a rare disease with an incidence of 1 in 20,000 to 30,000 births. There is no cure for KS, and conservative medical treatments are used to relieve symptoms and prevent disease progression. Lung transplantation (LT) is the only treatment option for end-stage KS. Since patients with KS have anatomical abnormalities such as situs inversus totalis, which often require surgery to correct, most reports are related to surgical techniques. Reports about morphological adaptations and changes in transplanted lung structure after LT in patients with KS are rare. We performed LT in a patient with KS and observed morphological adaptation of the lungs for 6 months on chest computed tomography using a quantitative evaluation tool (Chest Image Platform; Harvard University Disability Resources, Cambridge, MA, USA).

Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019: Expert Recommendations from The Korean Society for Thoracic and Cardiovascular Surgery.

Since the first reported case of coronavirus disease 2019 (COVID-19) in December 2019, the numbers of confirmed cases and deaths have continued to increase exponentially despite multi-factorial efforts. Although various attempts have been made to improve the level of evidence for extracorporeal membrane oxygenation (ECMO) treatment over the past 10 years, most experts still hesitate to take an active position on whether to apply ECMO in COVID-19 patients. Several ECMO management guidelines have been published recently, but they reflect some important differences from the Korean medical system and aspects of real-world medical practice in Korea. We aimed to find evidence on the efficacy of ECMO for COVID-19 patients by reviewing the published literature and to propose expert recommendations by analyzing the Korean COVID-19 ECMO registry data.

Multivariate Analysis of Risk Factor for Mortality and Feasibility of Extracorporeal Membrane Oxygenation in High-Risk Thoracic Surgery.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) as intraoperative cardiorespiratory support during lung transplantation is well known, but use for other types of surgery are limited. To assess risk factor for mortality after high-risk thoracic surgery and feasibility of ECMO, we reviewed. METHODS: This study was an observational study. Between January 2011 and October 2018, 63 patients underwent thoracic surgery with ECMO for severe airway disease, pulmonary insufficiency requiring lung surgery, and other conditions. RESULTS: In all, 46 patients remained alive at 30 days after surgery. The mean patient age was 50.38 ± 16.16 years. ECMO was most commonly used to prevent a lethal event (34 [73.9%]) in the Survival (S) group and rescue intervention (13 [76.5%]) in the Non-survival (N) group. In all, 11 patients experienced arrest during surgery (S vs N: 2 [4.3%] vs 9 [52.9%], p ≤0.001). The multivariate analysis revealed that arrest during surgery (odds ratio [OR], 24.44; 95% confidence interval [CI], 1.82-327.60; p = 0.016) and age (OR, 7.47; 95% CI, 1.17-47.85; p = 0.034) were independently associated with mortality. CONCLUSIONS: ECMO provides a safe environment during thoracic surgery, and its complication rate is acceptable except for extracorporeal cardiopulmonary resuscitation (ECPR).

Catastrophic Mechanical Complications of Extracorporeal Membrane Oxygenation.

Technical advances in extracorporeal membrane oxygenation (ECMO) have increased the number of cases that maintain longer duration. Long-term use of ECMO results in ECMO-related complications. Anticipation of the life-threatening mechanical complications and their management are critical for safe ECMO. In this study, we analyzed the incidence, nature, and risk factors of life-threatening mechanical complications during ECMO support. Furthermore, we presented our bedside algorithms to manage catastrophic ECMO complications. Data from 549 patients who underwent ECMO between December 2008 and December 2018 were retrospectively analyzed. The incidence of all life-threatening mechanical complications was 4.0%. Accidental decannulation (1.3%) was most common, followed by abrupt falling circuit flows (1.1%), pump failure (1.1%), circuit rupture (0.4%), and air in circuit (0.2%). Most (90.9%) of life-threatening events required circuit and cannula change, while 9.1% required vein collapse relief procedure. There was no death related to the event; however, six (27.3%) died during ECMO due to the underlying disease for which ECMO was required, and three (13.6%) died after weaning from ECMO. Multivariate regression analysis showed that awake ECMO and long-term ECMO support were significantly associated with life-threatening mechanical complications (p < 0.01). Our algorithm safely managed catastrophic ECMO problems without event-related deaths.

Noble Metal-Assisted Surface Plasmon Resonance Immunosensors.

For the early diagnosis of several diseases, various biomarkers have been discovered and utilized through the measurement of concentrations in body fluids such as blood, urine, and saliva. The most representative analytical method for biomarker detection is an immunosensor, which exploits the specific antigen-antibody immunoreaction. Among diverse analytical methods, surface plasmon resonance (SPR)-based immunosensors are emerging as a potential detection platform due to high sensitivity, selectivity, and intuitive features. Particularly, SPR-based immunosensors could detect biomarkers without labeling of a specific detection probe, as typical immunosensors such as enzyme-linked immunosorbent assay (ELISA) use enzymes like horseradish peroxidase (HRP). In this review, SPR-based immunosensors utilizing noble metals such as Au and Ag as SPR-inducing factors for the measurement of different types of protein biomarkers, including viruses, microbes, and extracellular vesicles (EV), are briefly introduced.

Total pleural coverage followed by lung transplantation in patient with lymphangioleiomyomatosis.

Tuberous sclerosis complex lymphangioleiomyomatosis (TSC-LAM) is a rare disease, which may develop an intractable pneumothorax. Chemical or mechanical pleurodesis is a general management to prevent recurrence of pneumothorax, rendering it difficult to later dissect the pleura and control intraoperative bleeding. Since total pleural coverage (TPC) alternative to pleurodesis has been firstly reported by Kurihara et al. (Jpn J Thorac Cardiovasc Surg 54:274, 2006), TPC was performed in case of a 46-year-old female with a secondary spontaneous pneumothorax caused by TSC-LAM and followed by lung transplantation. Final pathological report showed the reinforced visceral pleura in the absence of dense adhesions.

Comparative study between local anesthesia and general anesthesia in the treatment of primary spontaneous pneumothorax.

BACKGROUND: There is increasing interest in non-intubated video-assisted thoracoscopic surgery (VATS). At present, this method is used in various types of thoracic surgery. Especially, simple wedge resection via VATS is thought to be an optimal indication of non-intubated VATS. This study was performed to evaluate the usefulness of VATS bullectomy under local anesthesia by comparison with bullectomy under general anesthesia. METHODS: A total of 183 cases of wedge resection under general anesthesia and 52 cases of wedge resection under local anesthesia were examined. Medical records were retrospectively reviewed to assess the feasibility, usability, and cost effectiveness of wedge resection under local anesthesia. The preoperative clinical parameters, including age, sex, and the number of pneumothorax episodes and previous operations, were used to match cases and controls. RESULTS: There were no significant differences between the local and general anesthesia groups in operative time (57.5±23.1 and 56.6±25.6 min, respectively; P=0.857), type of operation [single-incision thoracoscopic surgery (SITS), n=48 and n=47, respectively; multi-port-VATS (M-VATS), n=4 and n=5, respectively; P=0.730], or chest tube indwelling time (3.6±1.5 and 4.4±2.5 days, respectively; P=0.064). The mean times from arrival at the operating room (OR) to skin incision (16.4±12.3 and 46.4±17.2 min, respectively; P<0.001), and from the end of surgery to arrival at the general ward (36.0±25.6 and 58.1±20.9 min, respectively; P<0.001) were significantly shorter in the local anesthesia group than the general anesthesia group. The total cost was significantly lower in the local anesthesia group than in the general anesthesia group (4,890.6±717.1 and 5,739.1±1,154.6, respectively; P<0.001). CONCLUSIONS: Local anesthesia shortened the overall hospital stay by reducing the interval between admission and surgery, allowing immediate ambulation after surgery. In addition, this method reduced costs by avoiding the need for anesthesia.

Clinical Result and Feasibility of Transport ECMO in Thoracic Transplantation.

INTRODUCTION: There is an increasing need for transport extracorporeal membrane oxygenation (ECMO) in thoracic transplantation. This study was performed to evaluate the safety and feasibility of transport ECMO in thoracic transplantation. PATIENTS AND METHODS: A total of 24 patients referred from outside hospitals for ECMO treatment used our interhospital ECMO transport system from December 2011 to October 2018. We retrospectively analyzed the clinical data to evaluate the feasibility and safety of transport ECMO for thoracic transplantations. RESULTS: The median transport distance was 34 km (interquartile range [IQR]: 29-45) and the median transport time was 38 minutes (IQR: 26-45). There were no adverse events during transit in any patient. ECMO weaning was possible in 19 patients (79%) and 13 patients (54%) were weaned from mechanical ventilation. Of these patients, only 14 (58%) underwent transplantation, of whom 8 received lung transplants (53%) and 6 received heart transplants (67%). Among the patients receiving transplants, intensive care unit discharge was possible in 9 patients (64%), and 8 patients (57%) were discharged home. CONCLUSIONS: Transport ECMO to the transplantation center is a useful strategy to rescue patients with cardiorespiratory failure who may require transplantation, providing an additional means of improving the chance of survival.

High-flow oxygen therapy for treating re-expansion pulmonary edema.

Re-expansion pulmonary edema (REPE) is a lethal complication, which usually occurs after rapid re-expansion of a collapsed lung following chest tube insertion. As REPE can induce respiratory failure, mechanical ventilation is necessary in some cases. However, ventilator therapy can worsen ventilation perfusion mismatch at the initial stage of the treatment procedure, and increases the risk of fatality. To resolve this problem, it is advisable to maintain spontaneous breathing without using a mechanical ventilator. A high-flow nasal cannula can supply a high concentration of oxygen while maintaining spontaneous breathing in patients with dyspnea, which has recently emerged as an alternative to ventilators. We introduced a high-flow nasal cannula to treat REPE instead of a mechanical ventilator and successfully treated a patient with severe REPE.

Should We Remove the Retrievable Cook Celect Inferior Vena Cava Filter? Eight Years of Experience at a Single Center.

BACKGROUND: The inferior vena cava filter (IVCF) is very effective for preventing pulmonary embolism in patients who cannot undergo anticoagulation therapy. However, if a filter is placed in the body permanently, it may lead to other complications. METHODS: A retrospective study was performed of 159 patients who underwent retrievable Cook Celect IVCF implantation between January 2007 and April 2015 at a single center. Baseline characteristics, indications, and complications caused by the filter were investigated. RESULTS: The most common underlying disease of patients receiving the filter was cancer (24.3%). Venous thrombolysis or thrombectomy was the most common indication for IVCF insertion in this study (47.2%). The most common complication was inferior vena cava penetration, the risk of which increased the longer the filter remained in the body (p=0.032, Exp(B)=1.004). CONCLUSION: If the patient is able to retry anticoagulation therapy and the filter is no longer needed, the filter should be removed, even if a long time has elapsed since implantation. If the filter cannot be removed, it is recommended that follow-up computed tomography be performed regularly to monitor the progress of venous thromboembolisms as well as any filter-related complications.

Surgical Outcomes of Pneumatic Compression Using Carbon Dioxide Gas in Thoracoscopic Diaphragmatic Plication.

BACKGROUND: Surgical correction needs to be considered when diaphragm eventration leads to impaired ventilation and respiratory muscle fatigue. Plication to sufficiently tense the diaphragm by VATS is not as easy to achieve as plication by open surgery. We used pneumatic compression with carbon dioxide (CO2) gas in thoracoscopic diaphragmatic plication and evaluated feasibility and efficacy. METHODS: Eleven patients underwent thoracoscopic diaphragmatic plication between January 2008 and December 2013 in Pusan National University Hospital. Medical records were retrospectively reviewed, and compared between the group using CO2 gas and group without using CO2 gas, for operative time, plication technique, duration of hospital stay, postoperative chest tube drainage, pulmonary spirometry, dyspnea score pre- and postoperation, and postoperative recurrence. RESULTS: The improvement of forced expiratory volume at 1 second in the group using CO2 gas and the group not using CO2 gas was 22.46±11.27 and 21.08±5.39 (p=0.84). The improvement of forced vital capacity 3 months after surgery was 16.74±10.18 (with CO2) and 15.6±0.89 (without CO2) (p=0.03). During follow-up (17±17 months), there was no dehiscence in plication site and relapse. No complications or hospital mortalities occurred. CONCLUSION: Thoracoscopic plication under single lung ventilation using CO2 insufflation could be an effective, safe option to flatten the diaphragm.

Successful Repair of Type I Endoleak Using the Frozen Elephant Trunk Technique.

Thoracic endovascular aortic repair (TEVAR) has emerged as an effective therapy for a variety of thoracic aortic pathologies. However, various types of endoleak remain a major concern, and its treatment is often challenging. We report a case of type I endoleak occurring 19 months after zone II hybrid TEVAR. The endoleak was successfully repaired by the frozen elephant trunk technique, without removal of a previous stent graft, combined with ascending aorta and total arch replacement.