Fluorescence Image-Based Evaluation of Gastric Tube Perfusion during Esophagogastrostomy

During esophagectomy and esophagogastrostomy, the prediction of anastomotic leakagerelies on the operating surgeon’s tactile or visual diagnosis. Therefore, anastomoticleaks are relatively unpredictable, and new intraoperative evaluation methods or tools areessential. A fluorescence imaging system enables visualization over a wide region of interest,and provides intuitive information on perfusion intraoperatively. Surgeons can choosethe best anastomotic site of the gastric tube based on fluorescence images in real timeduring surgery. This technology provides better surgical outcomes when used with anoptimal injection dose and timing of indocyanine green.

Extramedullary Hematopoiesis at the Posterior Mediastinum in Patient with Hereditary Spherocytosis: A Case Report

Thoracic extramedullary hematopoiesis (EMH) is a rare disease entity that is usually associated with hematologic disorders, such as myelodysplastic or hemolytic disease. Because thoracic EMH is usually encountered as a mass during radiologic examinations, it should be differentiated from posterior mediastinal neurogenic tumors. Here, the authors report a case of EMH associated with hereditary spherocytosis. The patient underwent a complete excision by thoracoscopic surgery to differentiate it from other mediastinal tumors.

Management of Severe Trauma Patients in the Emergency Intensive Care Unit

PURPOSE: The aim of this study was to evaluate the quality of the trauma care system of our hospital, in which emergency physicians care for major trauma patients in the emergency intensive care unit (ICU) in consultation with intervention radiologists and surgeons. METHODS: This was a retrospective observational study conducted in an emergency ICU of a tertiary referral hospital. We enrolled consecutive patients who had been admitted to our emergency ICU with major trauma from March 2007 to September 2010. We collected data with respect to demographic findings, mechanisms of injury, the trauma and injury severity score (TRISS), emergency surgery, angiographic intervention, and 6-month mortality. Then, we compared the observed and predicted survivals of the patients. The Hosmer-Lemeshow test and calibration plots by using 10 groups, one for each decile, of predicted mortality were used to evaluate the fitness of TRISS. P-values of greater than 0.05 represent a fair calibration. RESULTS: Among 116 patients, 12 (10.34%) were dead within 6 months after admission to the ICU, and 29 (25.00%) and 38 (32.80%) patients received emergency surgery and angiographic intervention, respectively. The mean injury severity score and revised trauma score were 36.97+/-17.73 and 7.84+/-6.75, respectively. The observed survival and the predicted survival of the TRISS were 89.66% (95% confidence interval [CI]: 84.03~95.28%) and 69.85% (95% CI: 63.80~75.91%), respectively. The calibration plots showed that the observed survival of our patients was consistently higher than the predicted survival of the TRISS (p<0.001). CONCLUSION: The observed survival for the trauma care system of our hospital, in which emergency physicians care for major trauma patients in the emergency ICU in consultation with intervention radiologists and surgeons, was higher than the predicted survival of the TRISS.

Evaluation of Lung Injury Score as a Prognostic Factor of Critical Care Management in Multiple Trauma Patients with Chest Injury

PURPOSE: Chest injuries in multiple trauma patients are major predisposing factor for increased length of stay in intensive care unit, prolonged mechanical ventilator, and respiratory complications such as pneumonia. The aim of this study is the evaluation of lung injury score as a risk factor for prolonged management in intensive care unit (ICU). METHODS: Between June to August in 2011, 46 patients admitted to shock and trauma center in our hospital and 24 patients had associated chest damage without traumatic brain injury. Retrospectively, we calculated injury severity score (ISS), lung injury score, and the number of fractured ribs and performed nonparametric correlation analysis with length of stay in ICU and mechanical ventilator support. RESULTS: Calculated lung injury score(<48 hours) was median 1(0-3) and ISS was median 30(8-38) in study population. They had median 2(0-14) fractured ribs. There were 2 bilateral fractures and 2 flail chest. Ventilator support was needed in 11(45.8%) of them for median 39 hours(6-166). The ISS of ventilator support group was median 34(24-34) and lung injury score was median 1.7(1.3-2.5). Tracheostomy was performed in one patient and it was only complicated case and ICU stay days was median 9(4-16). In correlation analysis, Lung injury score and ISS were significant with the length of stay in ICU but the number of fractured ribs and lung injury score were predicting factors for prolonged mechanical ventilator support. CONCLUSION: Lung injury score could be a possible prognostic factor for the prediction of increased length of stay in ICU and need for mechanical ventilator support.

Superior Vena Cava Resection and Reconstruction in Thoracic Malignancy / 대한흉부외과학회지

BACKGROUND: The benefit of superior vena cava (SVC) resection in thoracic malignancies remains controversial. We analyzed the results of extended resection in patients with thoracic malignancy involving the SVC. MATERIAL AND METHOD: From March 2000 to March 2009, we performed surgical resection and reconstruction in 18 thoracic malignancies involving the SVC. Ten male and 8 female enrolled and their mean age was 56 years. RESULT: SVC reconstruction was performed in 9 patients with polytetrafluoroethylene (PTFE) graft. Primary closure was possible in 6 patients by partially clamping the SVC. Patch angioplasty was performed in 3 patients with PTFE or autologous pericardial patch. Three-year survival was 58.0% and median survival time was 24.5 months. Disease specific survival and recurrence free survival were not significantly different between lung cancer and mediastinal malignancy. Obstruction of graft was detected in 4 patients during follow-up; SVC graft obstruction in 1 patient, and accessory graft between the innominate vein and right atrium in 3 patients. CONCLUSION: Extended resection of thoracic malignancies involving the SVC was a feasible method in selected patients. Although the morbidity rate was relatively high, mid-term survival was acceptable when complete resection was possible.

Surgical Experience with Killian-Jamieson Diverticulum: A case report / 대한흉부외과학회지

Killian-Jamieson diverticulum is a rare disease that is seen at the cervical esophagus. It has quite a different pathogenesis and anatomical location compared with that of Zenker's diverticulum. The pathophysiology and strategy for treating Killian-Jamieson diverticulum are not fully understood. We performed surgery using one incision for treating a case of Killian-Jamieson diverticulum and we review the medical literature that's related to this unusual diverticulum.

Spontaneous Hemothorax in a Patient with Type IV Ehlers-Danlos Syndrome: A case report / 대한흉부외과학회지

We successfully performed bleeding control using roll-gauze packing in a patient with Type IV Ehlers-Danlos syndrome and this patient was suffering from spontaneous hemothorax. Thoracotomy for controlling ongoing bleeding in a patient with Type IV Ehlers-Danlos syndrome should be performed as a last resort after due consideration.

Role of Pulmonary Metastasectomy of Hepatocellular Carcinoma after Liver Transplantation

PURPOSE: Liver transplantation (LT) has been advocated as a good management option for patients with hepatocellular carcinoma (HCC). The rate of HCC recurrence after LT is about 20%. Although the median survival time of patients with HCC recurrence is 7~9 months, the role of surgical treatment for metastatic tumors has been reported on. In this study, we evaluated the role of metastasectomy for treating patients with pulmonary metastasis from HCC after LT. METHODS: We retrospectively analyzed 10 patients with pulmonary metastasis after LT and who were treated between April 2005 and October 2007. The underlying liver disease was cirrhosis caused by chronic viral hepatitis. The surveillance protocol for HCC recurrence was as follows: assessing the serum alpha-fetoprotein level every 1 month, chest and abdomen-pelvic computed tomography every 3 months and a bone scan every 1 year or when bone metastasis was suspected. The patients with less than 3 metastatic lesions were recommended to undergo metastasectomy (Group S, n=6) and the patients with more 4 lesions were recommended nonsurgical management, including chemotherapy (Group N, n=4). RESULTS: All the metastatic lesions were detected on the protocol chest CT scans. The median recurrence time was 7.4 months (0.8~18.2) after LT; this was 11.0 (4.8~18.2) months for Group S and 2.0 (0.8~3.3) months for Group N. One patient had a single lesion and the others had multiple lesions on multilobes. The median survival times of Group S were 29.3 (18.5~41.3) months after pulmonary metastasis and 40.3 (23.3~48.0) months after transplantation; 5 patients had no recorded evidence of their disease status. The median survival time of Group N was 4.3 (4.0~6.3) months after metastasis and 6.2 (5.3~7.1) months after transplantation; all the patients have since died. CONCLUSION: The survival outcome seemed to be good for the patients who underwent pulmonary metastasectomy for HCC, if it was detected earlier and it was resectable (< or =3 lesions). However, further study is required for validating the survival benefit of pulmonary metastasectomy.

Role of Pulmonary Metastasectomy of Hepatocellular Carcinoma after Liver Transplantation

PURPOSE: Liver transplantation (LT) has been advocated as a good management option for patients with hepatocellular carcinoma (HCC). The rate of HCC recurrence after LT is about 20%. Although the median survival time of patients with HCC recurrence is 7~9 months, the role of surgical treatment for metastatic tumors has been reported on. In this study, we evaluated the role of metastasectomy for treating patients with pulmonary metastasis from HCC after LT. METHODS: We retrospectively analyzed 10 patients with pulmonary metastasis after LT and who were treated between April 2005 and October 2007. The underlying liver disease was cirrhosis caused by chronic viral hepatitis. The surveillance protocol for HCC recurrence was as follows: assessing the serum alpha-fetoprotein level every 1 month, chest and abdomen-pelvic computed tomography every 3 months and a bone scan every 1 year or when bone metastasis was suspected. The patients with less than 3 metastatic lesions were recommended to undergo metastasectomy (Group S, n=6) and the patients with more 4 lesions were recommended nonsurgical management, including chemotherapy (Group N, n=4). RESULTS: All the metastatic lesions were detected on the protocol chest CT scans. The median recurrence time was 7.4 months (0.8~18.2) after LT; this was 11.0 (4.8~18.2) months for Group S and 2.0 (0.8~3.3) months for Group N. One patient had a single lesion and the others had multiple lesions on multilobes. The median survival times of Group S were 29.3 (18.5~41.3) months after pulmonary metastasis and 40.3 (23.3~48.0) months after transplantation; 5 patients had no recorded evidence of their disease status. The median survival time of Group N was 4.3 (4.0~6.3) months after metastasis and 6.2 (5.3~7.1) months after transplantation; all the patients have since died. CONCLUSION: The survival outcome seemed to be good for the patients who underwent pulmonary metastasectomy for HCC, if it was detected earlier and it was resectable (< or =3 lesions). However, further study is required for validating the survival benefit of pulmonary metastasectomy.

Early Failure of the Shelhigh Pulmonary Valve Conduit in Ross Operation: Two case reports / 대한흉부외과학회지

It is very difficult to choose the ideal valved conduit used in right ventricle outflow reconstruction in child. We can use the cryopreserved homograft but there is a limit of appplication because of its difficulties in the size matching and supply capacity. The Shelhigh(R) porcine-valved conduit is commercially available and used as an alternative choice in these days. We report two cases of early Shelhigh conduit failure in right ventricular outflow tract after Ross operation in congenital aortic stenosis.

Arrhythmia Surgery in Fontan Operation / 대한흉부외과학회지

BACKGROUND: Refractory atrial arrhythmias in patients late after the Fontan operation result in significant morbidity and mortality. We reviewed our experience with arrhythmia surgery in patients who had Fontan operation. MATERIAL AND METHOD: Between July 1986 and December 2003, 275 early survivors after Fontan operation were reviewed. Fourteen patients underwent arrhythmia surgery at reoperation after Fontan operation, and mean age at reoperation was 16.8+/-7.1 (range: 4.5~30.6) years. Mechanisms of arrhythmia included atrial flutter in 8 patients, and atrial fibrillation in 2. Arrhythmia surgery has evolved from isthmus cryoablation in 12 patients to right-sided maze in 2 patients. Thirty-two patients underwent prophylactic isthmus cryoablation concomitantly at initial Fontan operation. RESULT: Postoperative arrhythmias occurred in 68 patients (24.7%) among 275. There was no early and late mortality after the arrhythmia surgery. After redo Fontan operation, all patients maintained normal sinus rhythm. Atrial flutter recurred in 3 patients who had sinus conversion with medication and 7 required permanent pacemakers with a mean follow-up of 26.5+/-29.1 (range: 2~73) months. All patients have improved to NYHA class I or II. After prophylactic cryoablation at initial Fontan operation, 29 patients (90.6%) had sinus rhythm, 1 patient had junctional tachycardia, 1 patient had sinus nodal dysfunction, and 1 patient had AV block with a mean follow-up of 51.3+/-19.8 (range: 4~80) months. CONCLUSION: Redo Fontan operation, and concomitant arrhythmia surgery reduced atrial arrhythmias and improved NYHA functional classification.

Long-term Results of Modified Lecompte Procedure for the Anomalies of Ventriculoarterial Connection / 대한흉부외과학회지

Background: The Lecompte procedure for transposition of the great arteries has an advantage because it obviates the need for an extracardiac conduit for the reconstruction of the pulmonary outflow tract. We evaluated the effectiveness and the application of the Lecompte procedure. Material and Method: A retrospective review was conducted of the records of 46 patients who underwent the Lecompte procedure during the past 15 years. Mean age at operation was 29.2+/-20.3 (range: 3~83) months. The diagnoses involved anomalies of the ventriculoarterial connection with ventricular septal defect and pulmonary outflow tract obstruction, such as transposition of the great arteries, double-outlet right ventricle, and double-outlet left ventricle. Result: Early mortality was 4.4% (2 of 46 patients) and late mortality was 6.8% (3 of 44). The mean follow-up was 11.2+/-6.9 years. Eighteen patients (43.9% of survivors, n=41) had pulmonary stenosis (pressure gradient above 30 mmHg), the main reason for which was a calcified monocusp valve (n=15, 83.3%). Seventeen of 46 patients (37.0%) underwent reoperation: 15 for pulmonary stenosis, 5 for residual ventricular septal defect, 4 for left ventricular outflow tract obstruction, 3 for pulmonary insufficiency, and 4 for other causes. The cumulative survival rates were 91.3+/-4.2%, and 87.0+/-5.8% at 10 and 15 years, respectively. The actuarial probabilities of freedom from reoperation for pulmonary stenosis were 90.6+/-4.5%, 73.9+/-7.3%, and 54.0+/-10.4% at 5, 10, and 15 years, respectively. Conclusion: The Lecompte procedure is an effective treatment modality. Repair in early age is possible with acceptable morbidity and mortality, but recurrent right ventricular outflow tract obstruction caused by degeneration of the monocusp valve is a problem that needs resolution.

VATS Resection of Giant Leiomyoma of the Esophagus: 1 case / 대한흉부외과학회지

A 59-year old woman visited us for incidentally detected posterior mediastinal mass. Preoperative esophagography, esophagoscopy, esophageal ultrasound and computed tomography showed a esophageal submucosal tumor. With the diagonsis of esophageal leiomyoma, the patient underwent right side video-assisted thoracoscopic surgery (VATS): The mediastinal pleura and the esophageal muscle layers were longitudinally opened and the tumor was enucleated. Esophagography performed at 6th postoperative day revealed no esophageal mucosal bulging or leakage. The patient was discharged reveiving a soft diet on the 7th postoperative day. ha

Thirteen-year Experience of Permanent Epicardial Pacing in Children / 대한흉부외과학회지

BACKGROUND: We investigated the longevity, thresholds of epicardial pacemaker and causes of reoperation in the pediatric patients who underwent epicardial pacemaker implantation performed during the last 13 years MATERIAL AND METHOD: 121 operations were performed in 83 patients from January 1989 to July 2002. We analyzed the stimulation threshold, resistance, R-wave and P-wave, and sensitivity of pacemaker lead at initial implantation. Longevity and causes of reoperations were investigated. RESULT: At implantation, epicardial ventricular mean stimulation threshold was 1.2+/-0.1 (0.1~5) mV, mean resistance was 519.1+/-18.1 (319~778) Ohm, and mean R-wave sensitivity was 8.9+/-0.7 (4~20) mV, and mean P wave sensivity was 2.5+/-0.7 (0.4~12) mV. The mean longevity of pacemaker generator was 64.7+/-3.7 (2~196) months. The reoperation free rate was 94.6% for 1 year, 93.6% for 2 years, 80.8% for 5years, 63.7% for 7 years, and 45.5% for 10 years. The causes of reoperation were battery waste in 26 cases and lead malfunction in 9 cases. There was no postoperative death related to pacemaker malfunction. CONCLUSION: In the childrens, average longevity of epicardial pacemaker was within acceptable range. 19.1% of the patients required pacemaker related reoperation. However, recent developments, including steroid eluting lead, 6.7% of the patients required pacemaker related reoperation, look promising in expansion of pacemaker life span.

Surgical Experience of Aortic Root Abscess with Complete AV Block and Pseudoaneurysm / 대한흉부외과학회지

A 42 year old male was operated with aortic root abscess and pseudoaneurysm. Aortic valve vegetations which measured 8x5 cm and root abscess were removed and debrided. We reconstructed root and noncoronary sinus with autopericardium. Antibiotics were administered for 4 weeks. In general, Aortic root abscess recurs frequently and mortality is high. It is usually requires early surgical eradication with antibiotics medication

Successful Treatment of Left Atrial Auricular Abscess

Mural endocarditis causing myocardial abscess without valvular involvement is very rare. We report an unusual case of left atrial auricular abscess which was successfully treated by surgical resection, treatment with antibiotics, and mediastinal irrigation. A 9-yr-old female patient with previous history of urinary tract infection was admitted because of persistent fever. Echocardiography and magnetic resonance imaging revealed massive pericardial effusion and a mass lesion at the left upper cardiac border. Pericardiocentesis isolated Staphylococcus aureus on culture. The patient underwent mass removal under cardiopulmonary bypass. The mass was located in the left atrial auricle with fibropurulent abscess formation inside. Postoperative mediastinal irrigation was performed using povidone iodine solution. Pathological examination of the mass showed organized thrombi with chronic fibrosing mural endocarditis.