Atypical Thymic Carcinoid in a Patient with Zollinger-Ellison Syndrome

Atypical thymic carcinoid is an extremely rare tumor with a poor prognosis. In addition to its known association with multiple endocrine neoplasia type 1, its hallmark characteristics include local invasion and early distant metastasis. In this report, we share our experience treating atypical thymic carcinoid in a patient with Zollinger-Ellison syndrome.

Atypical Thymic Carcinoid in a Patient with Zollinger-Ellison Syndrome / 대한흉부외과학회지

Atypical thymic carcinoid is an extremely rare tumor with a poor prognosis. In addition to its known association with multiple endocrine neoplasia type 1, its hallmark characteristics include local invasion and early distant metastasis. In this report, we share our experience treating atypical thymic carcinoid in a patient with Zollinger-Ellison syndrome.

Thoracic Air-leak Syndromes In Hematopoietic Stem Cell Transplant Recipients with Graft-versus-Host Disease: A Possible Sign for Poor Response to Treatment and Poor Prognosis

Bronchiolitis obliterans (BO) or bronchiolitis obliterans organizing pneumonia (BOOP) is one of manifestations of graft-versus-host disease (GVHD), a complication of hematopoietic stem cell transplantation (HSCT). Recently there are reports about thoracic air-leakage syndrome (TALS), but real incidence, clinical course, and implications of TALS remain unclear. Retrospective review of 18 TALS patients among 2,177 patients who received allogeneic HSCT between January 2000 to July 2007 was done. Clinical manifestations, treatments, and outcomes of TALS were reviewed. The incidence of TALS was 0.83% (18/2,177). The onset of TALS was mean 425.9+/-417.8 days (60-1,825 days) after HSCT, and the duration was mean 16.3+/-21 days (2-90 days). The most common types of TALS were spontaneous pneumothroax (n=14), followed by subcutaneous emphysema (n=6), pneumomediastinum (n=5), interstitial emphysema (n=2), and pneumopericardium (n=1). TALS persisted in six patients, who died during the same hospitalization. The 12 patients recovered from TALS, but only 2 survived, while others died due to aggravation of GVHD. TALS may complicate BO/BOOP and be an initial manifestation of BO/BOOP. TALS is hard to be resolved, and even after the recovery, patients die because of aggravation of GVHD. We suggest specifically in HSCT patients, when once developed, TALS seems hard to be cured, and as a result, be related to high fatality.

Upregulation of Connexin43 Expression in Mitral Valves in a Rabbit Model of Hypercholesterolemia / 대한흉부외과학회지

BACKGROUND: Connexin 43-mediated gap junctional communication plays an important role in atherosclerosis. Numerous studies have demonstrated a correlation between mitral valve annular calcification and atherosclerotic disease. However, the relevance of connexin 43 to mitral valve disease remains unclear. We hypothesized that the mechanism contributing to mitral valve disease is associated with alterations in cell-to-cell communication mediated by changes in Connexin 43 expression. MATERIAL AND METHOD: Twenty male New Zealand rabbits were divided into two groups: animals in group 1 (n=10) were fed a normal chow diet, whilst those in group 2 (n=10) received a diet containing 1% cholesterol for 12 weeks. After sacrificing the animals, the mitral valves were excised and analyzed with immunohistochemical staining and Real-time Reverse Transcriptase polymerase chain reaction (real time RT-PCR). RESULT: Myofibroblasts and macrophages were found concentrated within the endothelial layer on the ventricular side of the leaflet in the cholesterol diet group. Immunohistochemial staining showed elevated expression of connexin43 in the cholesterol diet group. Real-time RT-PCR revealed increased connexin43 mRNA levels in mitral valves from hypercholesterolemic animals. CONCLUSION: Our finding that connexin43 expression is increased in mitral valves of hypercholesterolemic rabbits suggests that alterations in cell-to-cell communication via connexin43 containing gap junctions play a role in the development of mitral valve disease in hypercholesterolemia.

The Short Term and Intermediate Term Results of using a T-tube in Patients with Tracheal Stenosis / 대한흉부외과학회지

BACKGROUND: The treatment of tracheal stenosis includes less invasive bronchoscopic intervention and more invasive segmental resection & anastomosis. Depending on the patient's clinical features, sometimes all these methods are inappropriate. Silicone T-tube stenting has recently been used as an alternative, safe management of tracheal stenosis. We studied the short term and Intermediate term results of using T-tubes in patients with tracheal stenosis, and this tracheal stenosis was caused by various underlying diseases. MATERIAL AND METHOD: We retrospectively reviewed 57 patients with tracheal stenosis and who were treated with T-tubes between Jan 1997 and Apr 2007. Based on the patient's medical records and the imaging studies, we evaluated the clinical findings and status of T-tube removal. RESULT: There was no T-tube related morbidity or mortality in this series. On follow-up, one patient underwent sleeve resection and end-to-end anastomosis. The T-tube could be successfully removed from 13 patients (13/57, 22.8%) without additional interventions. For another four patients, a T-tube was again inserted after removal of the first T-tube due to tracheomalacia or recurrent stenosis. Four patients died of underlying disease and cancer. The patients' gender and previous tracheostomy significantly affected T-tube removal. By contrast, multiple logistic regression analysis identified gender as a predictor of successfully removing a T-tube. Gender (p=0.033) and previous tracheostomy (p=0.036) were the two factors for success or failure of T-tube removal. CONCLUSION: A T-tube provided reliable patency of a stenotic airway that was caused by any etiology. We have proven that using a T-tube is safe and effective therapy for patients with tracheal stenosis for the short term or the intermediate term.

The Heart Rate and ECG Changes after Endoscopic Thoracic Sympathectomy in Patients with Primary Hyperhidrosis / 대한흉부외과학회지

BACKGROUND: Primary focal hyperhidrosis is characterized by overactivity of the sympathetic nervous function, and this has been effectively treated with endoscopic thoracic sympathetic denervation (ESD). The imbalance of sympathetic and parasympathetic nervous system that's created by ESD may affect the heart, lung and other thoracic organs. We analyzed the heart rate and ECG changes after performing ESD at our hospital, and this is the first such study that has been conducted on this. MATERIAL AND METHOD: Of the 263 patients who underwent ESD between October 1996 and October 2006, 130 had ECG before and after ESD, and they were classified into 3 groups according to the level of ESD: Group I (n=40) patients underwent ESD at the 2nd rib (T2ESD), Group II (n=80) at the 3rd rib (T3ESD) and Group III (n=10) at the 4th rib (T4ESD). RESULT: There was no mortality or major morbidity. Heart rate (HR) was significantly decreased from 71.6+/-10.6/min to 66.8+/-10.2/min after ESD (p<0.01); however, the PR (from 148.6+/-21.2 msec to 152.8+/-20.5 msec) and QTc (from 399.2+/-15.4 msec to 404.0+/-15.1 msec) intervals were significantly increased after ESD in the patients who suffered with primary hyperhidrosis (p<0.01). According to the level of ESD, there were significant changes in the HR and QTc interval in group I (T2ESD), the HR and PR interval in group II and the QTc interval in Group III. CONCLUSION: There were significant changes in the heart rate and ECG findings after ESD. The thoracic sympathetic denervation of T2, T3 and T4 affected the electrical activity of the heart at the resting state.

The Effects of the Warm Ischemic Time, the Preserving Temperature and the Cryopreservation Solution on the Viability of Tracheas / 대한흉부외과학회지

BACKGROUND: Tracheal reconstruction after extended tracheal resection still remains as a major surgical challenge because good clinical outcomes are usually correlated with limited tracheal resection. Recent investigations with a using cryopreserved trachea for the reconstruction of a trachea have been carried out to overcome this problem. In this study, we analyzed viability of tracheas, which is an important determining factor for the success of transplanting a cryopreserved trachea and the development of post-transplantation tracheal stenosis, according to three different experimental factors: 1) the warm-ischemic time, 2) the cryopreservation solution and 3) the preserving temperature, to determine a better cryopreservation protocol and a better composition of the cryopreservation solution. MATERIAL AND METHOD: Rats tracheas were harvested for different warm-ischemic times (0 hr, 12 hrs, 24 hrs). The tracheas were treated with recombinant insulin growth factor-1 (IGF-1) and they were stored at three different temperatures (4 degreesC, -80 degreesC, -196 degreesC) for two weeks. After two weeks, we thawed the stored trachea and isolated the cells of the tracheas with using type II collagenase. We cultured the cells for seven days and then we compared the cellular viability by the MTT reduction assay. RESULT: Though cryopreservation is required to preserve a trachea for a longer time period, the viability of the tracheas stored at -80 degreesC and -196 degreesC was significantly reduced compared to that of the tracheas stored at 4 degreesC. The viability of the tracheas with warm-ischemic times of 12 hrs and 24 hrs was also reduced in comparison to the tracheas with a warm-ischemic time of 0 hrs.Department of Thoracic and Cardiovascular Surgery, St. Mary's Hospital, The Catholic University of Korea College of Medicine Our data showed that the warm ischemic time and the parameters of cryopreservation negatively affect on trachea viability. However, a cryopresrvation solution containing IGF-1 improved the cellular viability better than the existing cryopreservation solution. For the warm ischemic time group of 0 hr, the addition of IGF-1 improved the viability of trachea at all the preserving temperatures. CONCLUSION: These experiments demonstrate that the viability of a cryopreserved trachea can be improved by modifying the components of the cryopreservation solution with the addition of IGF-1 and reducing the warm-ischemic time.

Multiple Pulmonary Benign Metastasizing Leiomyoma / 대한흉부외과학회지

Benign metastasizing leiomyoma is a rare disease that histologically shows features of a benign tumor; however it can metastasize to the lung or other organs. We report here on a case of a 53-year-old woman with benign metastasizing leiomyoma, and she was admitted to the hospital with symptoms of coughing for 2 months; she showed multiple diffuse nodular opacities of both lungs on a chest radiograph. She had undergone hysterectomy for leiomyoma of the uterus 13 years previously. Thoracoscopic lung biopsy was performed to rule out metastatic lung cancer. The pulmonary nodules appeared benign with a very low mitotic rate and they consisted of smooth muscle cells. The pathologic findings of the pulmonary nodules were consistent with benign metastasizing leiomyoma. The patient has been followed up closely without any specific therapy.

Secondary Esophageal Reconstruction for Esophageal Atresia / 대한흉부외과학회지

Jejunum and fasciocutaneous and myocutaneous flaps are theoretically recommended as esophageal substitutes in reconstruction of the esophagus after several occurrences of failed reconstruction. However, other esophageal substitutes should also be considered. Secondary esophageal reconstruction was successfully performed on a 24-year- old woman who had a history of cervical, thoracic, and abdominal operations and esophageal stricture secondary to several failed reconstructions for esophageal atresia and tracheo-esophageal fistula 21 years prior. The esophageal reconstruction was done subcutaneously by end-to-side anastomosis at the left cervical area using a deformed stomach graft. The patient was discharged with the ability to consume a regular diet after the operation.

Pericardial Cyst in the Rt. Subpulmonary Region: A case report / 대한흉부외과학회지

Pericardial cysts are uncommon benign congenital mediastinal lesions and they are most often found in either cardiophrenic angle. We present here one case of atypically located pericardial cyst that was located in the subpulmonary region. The clinicians should take into consideration this entity in the differential diagnosis of cystic lesion of the mediastinum. The diagnostic difficulties that are encountered and the utility of video-assisted thoracoscopy are described.

The Role of Surgery for the Treatment of Upper Esophageal Cancer / 대한흉부외과학회지

BACKGROUND: In the past, radiotherapy was the gold standard for the treatment of upper esophageal cancer, but the long-term follow-up was disappointing. There is still ongoing debate on the surgical management of these patients. This study was undertaken to update our experience with upper esophageal carcinoma and to evaluate the effectiveness of surgery. MATERIAL AND METHOD: From May 1995 to December 2005, 147 patients with esophageal cancer underwent surgery at our hospital. They were divided into two groups: one group consisted of 23 patients with upper esophageal (cervical and upper thoracic) cancer and another group consisted of 124 patients with lower esophageal (middle thoracic, lower thoracic and abdominal) cancer. We evaluated the effectiveness of surgical treatment between the 2 groups by measuring the rate of complete surgical resection, the postoperative complications, the postoperative mortality, tumor recurrence, the average life expectancy and the long-term survival. RESULT: On comparing both groups, there was no significant difference in the distribution of the pathological stage and no significant difference in the percentage of performing complete surgical resection. The percentage of postoperative complications was 39.1% (9 out of 23 patients) in the upper esophageal cancer group, and this was significantly higher than 16.9% (21 out of 124 patients) in the lower esophageal cancer group (p<0.05). However, there was no significant statistical difference between the groups for the percentages of postoperative mortality, tumor recurrence or the postoperative average life expectancy. CONCLUSION: There was no significant difference in operative mortality or surgical effectiveness between the 2 groups. Therefore, we thought that surgical treatment is also effective for treating upper esophageal cancer, but further investigation with large patient populations will be required.

Long Term Outcome of Endoscopically Clipping the Upper Part of R4 Sympathetic Block and R4 Sympathetic Block for the Treatment of Palmar Hyperhidrosis / 대한흉부외과학회지

BACKGROUND: Thoracic sympathetic block surgery is a safe and effective procedure for palmar hyperhydrosis, and this maintains sufficient moisture and prevents compensatory hyperhidrosis. To avoid compensatory hyperhidrosis, the authors performed sympathetic block surgery just above the R4 level to maintain sympathetic tone affecting the caudal area. MATERIAL AND METHOD: A total of 71 subjects (45 males and 26 females) were categorized into two groups. Group 1 (31 patients, mean age: 25.5 years) had clips placed both on the upper and lower part of R4 sympathetic ganglion, and group 2 (40 patients, mean age: 25.9 years) underwent clipping of the upper part of R4. Telephone surveys were done to collect data on 8 categories, and the average follow up interval was 24.9 months (group 1) and 18.9 months (group 2). RESULT: For group 1, 41.9% experienced no sweating and 48.4% replied they experienced some sweating depending on the surrounding conditions. Group 2 showed that 60% experienced no sweating and 35% replied they experienced some sweating depending on the surrounding conditions. 58.1% in group 1 experienced sweating right after the surgery, and 40.0% in group 2 experienced the same. Group 1 (38.1%) and group 2 (37.5%) replied they experienced no hand dryness and more patients in group 2 than in group 1 had hand dryness, but without uncomfortable symptoms. 71.0% (group 1) and 62.5% (group 2) replied they had no compensatory hyperhidrosis or related symptoms. One patient in group 1 and two in group 2 reported they regretted undergoing the procedure. The regions of compensatory hyperhidrosis were the back, thigh and chest in group 1 and the group 2 reported the back, chest, and abdomen in the order of frequency. Fewer incidences of the gustatory hyperhidrosis were noted in group 2. Most of the patients were satisfied with their treatment. CONCLUSION: Clipping the upper part of the R4 ganglion or R4 sympathetic block are both effective for treating palmar hyperhidrosis and these treatments decrease the occurrence or symptoms of compensatory hyperhidrosis. The upper R4 sympathetic block procedure is easier and safer with fewer incidences of gustatory hyperhidrosis and a higher percentage of patient satisfaction.

The Local Effect after Surgery in Non-small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Recent progress in the surgical therapy for lung cancer is one of the best examples of the successful evolution of clinical medicine. We reviewed our experience to evaluate the surgical outcomes in patients with non-small cell lung cancer. MATERIAL AND METHOD: We reviewed clinical records of 432 consecutive patients with proven non-small cell lung cancer who underwent complete removal of the primary tumor together with hilar and mediastinal lymph nodes from 1995 to 2005. The clinical characteristics, surgical methods, and recurrence patterns were analyzed. RESULT: Lobectomy was the most common procedure (66.7%) performed and sleeve lobectomy was the least (5.6%). In 179 patients (42.6%) the recurrence was noted and the regional recurrence (67 cases, 16.0%) was less than systemic recurrence (112 cases, 26.7%). The main sites of regional recurrence were hilum (25 cases, 37.3%) and ipsilateral mediastinum (17 cases, 25.4%). The hospital mortality rate was 2.8% (12/432 cases) and resection-morbidity rate was 12.5% (54/432 cases). CONCLUSION: The low recurrence rate, especially regional recurrence rate indicated that our surgical procedures with preoperative measures were considered useful and effective.

Pulmonary Resection for Invasive Pulmonary Aspergillosis in Hematological Malignancy Patients / 대한흉부외과학회지

BACKGROUND: Invasive pulmonary aspergillosis, a frequent fungal infection in immunocompromised patients, is known to have a poor prognosis despite the use of antifungal therapy in leukemic patients. We studied the outcome of surgical resection of invasive pulmonary aspergillosis where bleeding tendency, localized recurrence of infection, and incidence could be reduced. MATERIAL AND METHOD: We retrospectively reviewed 14 patients with a hematological malignancy where invasive pulmonary aspergillosis was diagnosed during the 10 years between 1998 and 2007. From the medical records, we reviewed the type and treatment of the hematological malignancy, including the diagnostic methods of invasive pulmonary aspergillosis, the preoperative hematological conditions and their management, and the surgical methods and records. We also analyzed the development of postoperative complications and patient mortality, the recurrence of postoperative invasive pulmonary aspergillosis, and if the patients had a bone marrow transplant. RESULT: Fourteen patients with invasive pulmonary aspergillosis and a hematological malignancy underwent a pulmonary lobectomy. One patient had a complication of bronchopleural fistula, but there were no other serious complications such as bleeding or wound infection, and none of the patients died postoperatively. CONCLUSION: We have shown that pulmonary lobectomy is a safe and effective therapy for invasive pulmonary aspergillosis in patients with hematological malignancies that allow further treatment of the hematological malignancy.

Clinical Analysis of Pulmonary Hamartoma: 37 Cases / 대한흉부외과학회지

BACKGROUND: Pulmonary hamartomas are the most common form of pulmonary benign tumors, and they occur in approximately 2~5% of all pulmonary neoplasm. However, only a few reports have been published on the clinical characteristics of pulmonary hamartoma in Korea. MATERIAL AND METHOD: The charts, X-rays and pathological specimens of 37 pulmonary hamartoma patients who were diagnosed by a pathological examination from January of 2000 to May of 2005 at the Catholic Medical Center were retrospectively reviewed. RESULT: The peak incidence of the tumor occurred in the seventh decade of life (32.4%). There were 23 men (62.6%) and 14 women (37.8%), with mean age of 55.6 years. Twenty-six patients (70.3%) were asymptomatic and 11 patients (29.7%) had symptoms. A total of 29 tumors (78.4%) were parenchymal, and 8 (21.6%) were endobronchial. Twenty cases (54.1%) were in the right lung and 17 cases (45.9%) were in the left lung. The right lower lobe was most commonly involved. Thirty-two (86.5%) hamartomas were diagnosed by surgical resection, 4 cases (10.8%) were diagnosed by bronchoscopic biopsy and 1 case (2.7%) was diagnosed by a fine needle aspiration biopsy. Thirty-four hamartomas (91.9%) were managed by surgical resection without complication. No recurrence or malignant changes were seen during the follow up period. CONCLUSION: Pulmonary hamartomas are most common in males during their fifth to seventh decade and they more commonly involve the right lung. No recurrence or malignant changes were seen during the follow up period.

The Patterns of Recurrence after Surgery for Non-small Cell Lung Cancer

PURPOSE: Recent progress in the surgical therapy for lung cancer is one of the best examples of the successful evolution of clinical medicine. We reviewed our experience to evaluate the surgical outcomes in patients with non-small cell lung cancer. MATERIALS AND METHODS: We reviewed clinical records of 236 consecutive patients with proven primary non-small cell lung cancer who underwent complete removal of the primary tumor together with hilar and mediastinal lymph nodes from 1995 to 2005. The clinical characteristics, surgical methods, and recurrence patterns were analysed. RESULTS: The patients of stage III and IV were 71 cases (35.9%) and 2 cases (1.0%) respectively, and neoadjuvant therapy was done in 62 patients. Lobectomy was the most common procedure (69.7%) performed and pneumonectomy was the least (5.6%). In 81 patients (40.9%) the recurrence was noted and the regional recurrence (27 cases, 13.6%) was less than systemic recurrence (54 cases, 27.3%). The main sites of regional recurrence were hilum (11 cases, 40.7%) and ipsilateral mediastinum (9 cases, 33.3%). CONCLUSION: These data indicated that our surgical methods were useful and effective

Interstitial Pneumonia and Lung Cancer Surgery / 대한흉부외과학회지

BACKGROUND: Interstitial pneumonia is associated with an increased risk of lung cancer but the outcome of surgical resection in this setting is unknown. The purpose of this study was to determine the relationship between pre-operative interstitial pneumonia (IP) and post-operative respiratory failure. MATERIAL AND METHOD: A retrospective review of 672 patients with lung cancer who underwent curative pulmonary resection at the Hospital of Catholic University Medical College between 1997 and 2005 was undertaken. The patients were divided into two groups according to preexisting interstitial pneumonia and not by the pre-operative chest HRCT or findings of pathologic papers. The pre-operative data and cancer-related findings were analyzed between the IP group and non-IP group, and between the respiratory failure group and non-failure group in IP patients. RESULT: Twenty-eight patients (4.2%) of the developed post-operative respiratory failure and this proved to be fatal in 21 of these patients. We could find preoperative interstitial pathology in 53 patients (7.9%) among the 672 patients. The incidences of respiratory failure were 11.3% (6/53 cases) and 3.6% (22/619 cases) in IP group and non-IP group respectively. CONCLUSION: Interstitial pneumonia was considered one of the risk factors for developing postoperative acute respiratory failure in patients with lung cancer.

Clinical Evaluation of Instrumental Esophageal Perforation / 대한흉부외과학회지

BACKGROUND: Esophageal perforation is an uncommon problem, but it is associated with high mortality. We performed a retrospective review of patients with instrumental esophageal perforation to assess the outcome of current management techniques. MATERIAL AND METHOD: We retrospectively analyzed all cases of instrumental esophageal perforation diagnosed at our hospital from January 1999 through to March 2005. The study group consisted of 12 patients (8 women and 4 men) with a mean age of 48.8 years (range, 21~83 years). We reviewed the effects of the surgical or medical treatments in various conditions of patients, such as of various sites of perforation and time delayed after injury. RESULT: Perforations were due to diagnostic endoscopy (50.0%, 6/12), esophageal bougination for benign stricture (33.3%, 4/12), endoscopic port insertion (8.3%, 1/12), and tracheal intubation (8.3%, 1/12). The perforated sites were thoracic in 7 patients and cervical in 5. The treatment included resection and reconstruction (5 cases), incision and drainage (4 cases), medical treatment (2 cases), and closed thoracostomy drainage only (1 case). Post-operative complications of transient pneumonia and wound infection were developed in 1 patient respectively. Both occurred in two patients with diffuse mediastinal abscess formation. The overall mortality was 8.3% (1/12) in one old patient who was managed medically for cervical esophageal perforation. CONCLUSION: We concluded that surgical treatment for esophageal perforations was safe and effective whether diagnosed early or lately.

Modified Tracheostomy for Severe Tracheal Stenosis / 대한흉부외과학회지

When tracheal invasion of a malignant tumor or tracheal stenosis of a benign origin exists at the lower or anterior part of the trachea, tracheal intubation or conventional tracheostomy may be difficult, and in these cases a modified tracheostomy through the lower or lateral part of the trachea would be necessary. We present 6 cases of modified tracheostomy performed with satisfactory results in severe tracheal stenosis that developed in the lower or anterior part of the trachea.

The Evaluation of Postoperative Acute Respiratory Failure in Primary Lung Cancer with Interstitial Pneumonia

PURPOSE: Since acute respiratory failure was one of the most fatal postoperative complications in lung cancer surgery, to know its incidence, and predisposing factors is very important. The purpose of this study was to determine the relationship between pre-operative interstitial pneumonia (IP) and post-operative acute respiratory failure. MATERIALS AND METHODS: A retrospective review of 672 patients with lung cancer who underwent curative pulmonary resection at the Hospital of Catholic University Medical College between 1997 and 2005 was undertaken. The patients were divided into two groups according to preexisting interstitial pneumonia or not by pre-operative chest HRCT or findings of pathologic papers. RESULTS: Twenty-eight patients (4.2%) developed post- operative respiratory failure and this proved to be fatal in 21 of these patients. We could find preoperative interstitial pathology in 53 patients (7.9%) among the 672 patients. The incidences of respiratory failure were 11.3% (6/53 cases) and 3.6% (22/619 cases) in IP group and non-IP group respectively. CONCLUSION: Interstitial pneumonia considered of one of the risk factors for developing postoperative acute respiratory failure in patients with lung cancer.