A Case of Arteriovenous Fistula between Common Carotid Artery and Internal Jugular Vein / 대한이비인후과학회지

Traumatic arteriovenous fistula between common carotid artery and internal jugular vein is extremely rare. Major cervical vascular injury may present as vigorous external bleeding, an expanding or stable cervical hematoma, or a hemispheric neurologic deficit. A rapidly expanding hematoma is immediate to the patient's airway and severe ongoing hemorrhage may lead to exanguination. The authors have experienced a case of traumatic pseudoaneurysm and arteriovenous fistula between common carotid artery and internal jugular vein. We treated this case successfully with exploration and vascular autograft, and so, we report it with a review of the literature.

Tricuspid Replacement through Right Thoracotomy in Reoperation: A case report / 대한흉부외과학회지

In an extremely enlarged right heart, the repeated midline sternotomy was considered to involve the risk of massive hemorrhage. A right thoracotomy provides a convenient and safe way to approach the tricuspid valve in patient who have had previous heart surgery through a midline sternotomy.

Experience of Reoperation after Valve Replacement Using Mechanical Heart Valve: 8 cases / 대한흉부외과학회지

Eight patients underwvnt reoperation after valve replacement surgery with a mechanical valve from January, 1992 to December, 2003. Among the various indications for reoperation, there were 4 patients with paravalvular leakage; 3 patients underwent resuturing of the area of leakage and one patient underwent redo valve replacement. Among the three patients with stenosis due to thrombosis of the valve, 2 patients underwent redo valve replacement and one patient underwent thrombectomy. In one patient, the valve functioned normally, but stenosis was caused by overgrowth of the patient and redo valve replacement was done 123 months later. There was no postoperative mortality or morbidity. After an average of 51 months (2~134 months) of postoperative follow up, the patients were in good condition and were able to maintain a NYHA functional class of I or II. The operative method used, whether it be a redo valve replacement or valve sparing method, depends upon the type of lesion and the anatomic structure.

Clinical Analysis of the Operative Results of the Type A Aortic Dissection according to the Location of the Intimal Tear / 대한흉부외과학회지

BACKGROUND: The location of intimal tear can vary in type A acute aortic dissection. The aim of this study was to assess the operative result according to the intimal tear site. MATERIAL AND METHOD: From January, 1995 to May, 2003, 18 patients underwent surgery for acute type A aortic dissection. The patients were classified according to the intimal tear site. In Group I (n=11), the intimal tear site was located within the ascending aorta, in Group II (n=7), the intimal tear site was located in the aortic arch, descending aorta, or intramural hematoma only. All clinical data were analyzed retrospectively. RESULT: In Group I, the operative time, cardiopulmonary bypass time, aorta cross clamp time and circulatory arrest time were 381.5+/-81.0 min, 223.5+/-42.5 min, 146.4+/-34.8 min and 36.5+/-17.4 min, respectively; and in group II, 461.7+/-54.0 min, 252.5+/-45.3 min, 162.5+/-45.3 min and 47.0+/-14.4 min respectively. All of those were greater in group II. The overall hospital mortality rate was 27.8% (5/18) and was significantly higher in Group II (57.1%)(p=0.003) compared to that in Group I (9.1%). The causes of death were hemorrhage (n=1) in group I and hemorrhage (n=2), multiple organ failure (n=1), and rupture of abdominal aorta (n=1) in group II. CONCLUSION: Surgical treatment of acute type A aortic dissection with intimal tear in the ascending aorta results in an acceptable mortality rate, but in patients with intimal tear in the aortic arch or descending aorta, the operative mortality still remains high when only ascending aorta replacement was performed. In these circumstances, in order to improve surgical results, efforts to include the intimal tear site in the operative procedure will be needed.

Resternotomy for Recurrent Aortic Aneurysm Adherent to the Sternum Under Deep Hypothermic Circulatory Arrest / 대한흉부외과학회지

Reoperation on the recurrent aortic aneurysm adjuvent to sternum remains a challenging problem in regard to the risk of the massive hemorrhage at the time of resternotomy resulting from inadvertent entry into the aneurysmal sac. The cardiopulmonary bypass technique of femoral cannulation and deep hypothermic circulatory arrest can provide a safe resternotomy. The left ventricle is likely to distend due to lack of contraction with ventricular fibrillation during core cooling. To prevent ventricular distention during core cooling, sufficient venous drainage is mandatory. We report a technique in which deep hypothermic circulatory arrest is achieved before resternotomy without left ventricular distention by active venous drainage using centrifugal pump.

Bronchopleural Fistula after Pneumonectomy: Autosuture Versus Manual Suture / 대한흉부외과학회지

BACKGROUND: Staple closure of bronchial stump was compared with manual suture closure among 100 cases of pneumonectomy during the recent 5-year period. We have reviewed the incidence of bronchpleural fistula between autosutured group and manual sutured group. MATERIAL AND METHOD: During the recent 5-year period, 100 patients underwent pneumonectomy at Hanyang University Hospital. Staple closure of bronchial stump was performed in 65 patients and manual suture in 35 patients. There were 55 males and 10 females in the autosutured group, and 26 males and 9 females in manual sutured group, which showed no significant statistical difference between the two groups. The mean ages of patients for autosutured group and manual sutured group were 56.7+/-10.3 years and 61.4+/-9.2 years, respectively, which showed no significant statistical difference between the two groups. There were 38 cases of left pneumonectomy and 27 cases of right pneumonectomy in autosutured group, and 22 cases of left pneumonectomy and 13 cases of right pneumonectomy in manual sutured group. There were 53 cases of malignancy and 12 cases of benign imflammatory disease in autosutured group, and 27 cases of malignancy and 7 cases of benign imflammatory disease in manual sutured group. RESULT: The incidence of bronchopleural fistula was 6.1% in autosutured group and 5.7% in manual sutured group. The incidence of other postoperative complication between the two groups showed no significant statistical difference. CONCLUSION: The incidence of bronchopleural fistula between autosutured group and manual sutured group was not different stastically. Both method for closure of bronchial stump can be performed in pneumonectomy.

Clinical Analysis of the Recent Results of Coronary Artery Bypass Grafting / 대한흉부외과학회지

BACKGROUND: Previous reports present that the early results of coronary artery bypass grafting (CABG) has been improving with the accumulation of surgical experience. We conducted a retrospective analysis of the patients who received CABG to evaluate the recent results of CABG. MATERIAL AND METHOD: Between January 1996 and August 2001, 154 patients underwent CABG at Hanyang University Hospital. There were 47 patients(group I) who were operated between 1996 and 1998, and 107 patients(group II) who were operated thereafter. The preoperative diagnosis, operative procedure, mortality, and complications were analyzed retrospectively. RESULT: There were 35 males and 12 females in group I, and 78 males and 29 females in group II, which shows similar ratio of sexes between the two groups. The average age of patients for group I and group II was 55.9+/-6.2 years and 61.0+/-8.0 years, respectively, showing a significant increase in group II(p<0.05). The average left ventricular ejection fraction(LVEF) for group I and group II was 54.6+/-11.8% and 56.9+/-13.0%, respectively. The number of patients who had previous MI in group I and group II were 13 patients(27.7%) and 14 patients(13.1%), respectively, which shows a significant difference (p<0.05). All procedures were performed using the cardiopulmonary bypass(CPB) and moderate systemic hypothermia. Myocardial protection was achieved using intermittent hypothermic ischemia under ventricular fibrillation state or cold crystalloid cardioplegic solution for most of group I patients, whereas cold blood cardioplegic solution was used for group II patients. The mean CPB times for group I and group II were 149.2+/-48.7 minutes and 113.1+/-30.6 minutes, respectively. The mean aortic cross clamp times for group I and group II were 81.3+/-26.5 minutes 72.2+/-23.9 minutes, respectiely. These figures show that CPB and aortic cross clamp times were significantly reduced in group II(p<0.05). The use of the left internal thoracic artery(LITA) was increased from 42%(20/47) for group I to 81% (87/107) for group II. The mean number of grafts also significantly increased from 2.5+/-0.6 for group I to 3.0+/-1.1 for group II(p<0.05). Intra-aortic balloon pump(IABP) was applied in 7 cases in group I and 17 cases in group II. Of these, 28.6%(2/7) and 52.9%(9/17) were broadly applied preoperatively in patients with LVEF<40% or congestive heart failure. The operative mortalities for group I and II were 10.6%(5/47) and 0.9%(1/107), respectively, which shows significant decrease for group II(p<0.05). CONCLUSION: This report suggest that CABG using CPB can recently be performed more safely in virtue of the accumulation of surgical experience with reduction in CPB and aortic cross clamp times and improved surgical techniques and myocardial protection. And we think that the optimal treatment of patients with left ventricular dysfunction associated with congestive heart failure and the extended application of IABP, especially have contributed to the reduction of operative mortality and morbidity.

Gastropericardial Fistula as a Late Complication after Esophagectomy with Esophagogastrostomy: A case report / 대한흉부외과학회지

A 56 year-old man complaining of dry cough, dyspnea, chest pain, fever, and chills was admitted to the emergency room. The patient had a history of esophagectomy and esophagogastrostomy and subsequent radiotherapy because of an esophageal cancer. After the emergency echocardiography revealed a small amount of pericardial effusion and pneumopericardium. Upper GI contrast study showed a fistulous tract between the stomach and the pericardium, and an emergency operation was done under the diagnosis of gastropericardial fistula. The patient expired postoperative seven days later. Gastropericardial fistula caused by a peptic ulcer perforation after the esophagectomy and esophagogastrostomy operation is a very rare complication and brings forth a disastrous result. Early detection using the chest radiography, electrocardiogram, upper GI study, echocardiography and a review of physical examination, and an immediate treatment are therefore mandatory.

Massive Edema of the Lower Extremity after Surgery for Abdominal Aortic Aneurysm: A case report / 대한흉부외과학회지

71 years old man was operated on due to abdominal aortic aneurysm associated with complete occlusion of left common iliac artery.The coexisting chronic deep vein thrombosis of the left femoral and iliac vein was not diagnosed preoperatively.Resection of aneurysm and Y-graft interposition was performed.Recurrent edema and pain occured to the left lower extremity immediately postoperatively,which aggrevated with the lapse of time,resulting in fatal extensive venous thrombosis.This report regards the surgical treatment and complication of the aortoiliac occlusive disease associated with chronic deep vein thrombosis.

Analysis of Postpneumonectomy Complication without Balanced Chest Bottle / 대한흉부외과학회지

BACKGROUND: Pneumonectomy carries the possibility of numerous dangerous complications as well as the vast effect the operation itself has on the cardiopulmonary function. Most of operations are done with the insertion of the chest tubes upon completion, but because of the high incidence of pyothorax as its complications, we have tried to analyze and compare the cases without inserting the chest tubes. MATERIAL AND METHOD: During a 5 year period from January, 1996 to December 2000, 100 cases, which were operated at the Hanyang University Hospital, were selected using the patient's charts. The age, gender, indication of operation, associated diseases, and operation site(left or right) were classified accordingly and the postoperative complications and mortality were statistically analyzed using the X2-test. After resecting the lung, the intrathoracic pressure was set at -15~-20cm H2O using the nelaton catheter, and the thoracotomy site was then closed. The gradual collection of the fluid and blood in the thorax of the operated side, as well as the mediastinum location, were observed carefully for 4~5 days postoperatively with the aid of the simple chest x-rays. RESULT: Of the 100 cases, 16 cases of pulmonary tuberculosis(16%), 81 cases of lung tumor(81%), 2 cases of bronchiectasis(2%), and 1 case of aspergilloma associated bronchiectasis were noted. There were 8 mortality cases(8%), and of the 34 cases(34%), 44 complications were noted. The age, sex, and operation site(left or right) were not statistically significant with the complications. 7 of the 16 cases of pulmonary tuberculosis(44%) and 27 of the 81 cases of lung tumor(33%) had complications, but they were found not to bestatistically significant. The increase of the complication rate in the pulmonary tuberculosis patients was 3.86. The evidence of postoperative bleeding was observed in 6 cases with the 3 cases being the pulmonary tuberculosis patients and the 3 cases were others. This shows that the increase in postoperative bleeding in the pulmonary tuberculosis is statistically significant(p=0.019). Of the 100 cases, there were 8 mortality cases(8%), with 5 cases from the 81 cases of the lung tumor group(6.1%), 3 cases from the 16 cases of pulmonary tuberculosis group(18.7%). CONCLUSION: The mortality and complication rates of the pneumonectomy operation with or without the insertion of the chest tube were similar to the previous reports, and we can conclude that the pneumonectomy without the insertion of the chest tube is also a good method, and We expect that this method will decrease the infection rate. The high risk group of mortality and complications was the pulmonary tuberculosis patients.

Surgical Treatment of Well-Differentiated Fetal Adenocarcinoma: A case report / 대한흉부외과학회지

WDFA(Well-differentiated fetal adenocarcinoma) histologically resembles pulmonary blastoma. It is also thought to be a subtype of pulmonary blastoma, which has differentiated epithelial features resembling the fetal lung among its epithelial features and sarcomatous features. We recently encounted a patient who underwent surgery for WDFA. A 19-year-old man had a mass shadow in the upper lobe of the left lung. The tumor was diagnosed as pulmonary blastoma as a result of fine needle aspiration biopsy, and left upper lobe lobectomy was performed. No sarcomatous features was observed on postoperative histologic assessment, and the patient was diagnosed as having WDFA. This case is reported with a discussion of the literatures.

Congenital Cardiac Anomaly Combined with the VATER Association: A case report / 대한흉부외과학회지

VATER is a complex anomaly of multiple organs and often combined with cardiac anomalies. However, it can be cured with active surgical intervention. We achieved successful result with aggressive surgery in the patient with VATER and report it with references.

Aortoenteric Fistula: one case report / 대한흉부외과학회지

Secondary aortoenteric fistula is a rare but fatal complication of reconstructive aortoiliac surgery. This disease entity could be divided into true aortoenteric fistula and paraprosthetic enteric fistula. The prevention, diagnosis and treatment of this complication remains a challenging problem. We report a 39 year old man who was diagnosed as paraprosthetic enteric fistula in endoscopy and operated 41 months after reconstructive aortoiliac surgery due to the infected pseudoaneurysm.

Langerhans' Cell Histiocytosis in Chest Wall / 대한흉부외과학회지

Langerhans' Cell Histiocytosis(LCH) is a disease of unknown origin, characterized by abnormal proliferation of Langerhans' cells. Previously, it has been called histiocytosis X, which included eosinophilic granuloma, Hand-Sch ller-Christian's disease, and Letterer-Siwe disease. Any organs or tissues such as skin, lymph nodes, bone and bone marrow can be involved. However, LCH of chest wall is rarely reported in our country. We experienced a 18 month old male child, who had osteolytic lesion involving the rib with axillary lymph node metastasis. The tumor was confirmed as LCH after surgery.

Thromboendarterectomy of Chronic Pulmonary Thromboembolism: A Case Report / 대한흉부외과학회지

Chronic pulmonary artery thromboembolism is a relatively rare phenomenon causing hypoxia and pulmonary hypertension that eventually leads to respiratory failure and right heart failure. Patients with acute pulmonary artery thromboembolism are generally treated with antithrombotics and thrombolytics. However, in cases with chronic pulmonary artery thromboembolism the fibrinized thrombus is so strongly adhered to the pulmonary artery wall that medical treatment becomes ineffective and surgical treatment must then be considered. We report a 47year old patient, with a history of repeated admission due to unresolved chronic obstructive pulmonary disease and chronic pulmonary artery thromboembolism at a local hospital, who underwent a successful endarterectomy of pulmonary artery thromboemboli using intermittent total circulatory arrest.

Surgical Management of Critical Pulmonary Stenosis: A case report / 대한흉부외과학회지

Although pulmonary valvular stenosis with intact ventricular septum is a common congenital abnormality, critical pulmonary stenosis of its severe form in the neonate is rare and highly fatal. With the development of percutaneous balloon valvuloplasty, surgical treatment is even more rare. This report is on a 2 day old male neonate with a critical pulmonary stenosis with intact ventricular septum who suffered from severe cyanosis and hypoxemia. Oxygen was inhalated and Prostaglandin E1 was infused initially and then arterial PO2 was increased from 19 mmHg to 54 mmHg. Percutaneous balloon valvuloplasty was attemped; however, the guidewire could not pass through the stenotic pulmonary valve, and during the procedure right ventricular perforation was suspected due to the presence of dye in the pericardial space. Emergency transarterial pulmonary valvotomy was performed using normothermic cardiopulmonary bypass. Postoperatively, the patient was in fair condition in the ICU and presently is in good condition at 6 months postoperative follow up.

Nonlinear Cardiac Dynamics and Morning Dip: An Unsound Circadian Rhythm

OBJECTIVES: We studied the circadian rhythm of nonlinear heart rate dynamics in healthy subjects. BACKGROUND: The frequency of sudden cardiac death increases in the morning. The relationship between decreased complexity of heart rate dynamics and sudden cardiac death has been documented. An understanding of the circadian variation in the complexity of cardiac dynamics may be important and to predict and prevent this sudden cardiac death. METHODS: Dynamic 24-hour electrocardiographic recordings were obtained from 30 healthy ambulant subjects aged 41 to 50 years and the digitized data was partitioned into sections of 30 minutes' duration. For each section, four indexes obtained from separate algorithms of nonlinear dynamics of RR interval - correlation dimension, Lyapunov exponent, approximate entropy, and fractal dimension - were calculated. Normalized low- (0.04-0.1 hertz) and high-frequency (>0.15 hertz) components were also calculated. RESULTS: All the four indexes of nonlinear dynamics showed a remarkably similar circadian rhythm: a prominent morning dip preceded by a steep decline during the late night, a recovery during the evening and a peak around midnight. In the morning, the low frequency component rose rapidly with concomitant withdrawal of the high frequency component. CONCLUSION: The complexity of cardiac dynamics decreases significantly in the morning, and this may contribute to the ominously increased rate of cardiac death in the morning hours.

Primary Malignant Pericardial Mesothelioma (PMPM): A case Report / 대한흉부외과학회지

Primary malignant pericardial mesothelioma(PMPM) is more rare than heart tumor, and the term of mcsothelioma was first used by Adami in 1910, although the lesion was Hrst descripted by Wagner in 1870. Most of 1:le reported 40 cascs have becn diagnosed on autopsy. Antemortem diagnosis are rarely reported with only 40 cases in the world. According to Cohen, its incidence in 500,000 autopsies were 2.2. An analysis of the recent review shows that an antemortem diagnosis was made in only 19~25% of total cases. This report co sist of a case of our experience of PMPM.

Inflammatory Pseudotumor of the Entire Left Lung: 1 operative case report / 대한흉부외과학회지

A case of inflammatory pseudotumor of the entire lung In a 61-ycar-old man is prcscntcd. The respiratory symptoms developed 2 months ago and progressed rapidly and the diagnosis of chronic pneumonia with ateletectasis of the entire lung, destroyed lung by tuberculosis and sepsis hAd to be ruled out The operative finding was different from our expectation. This case suggests that the Inflammatory pseudotumor can manifest as a whole lung-involving ass. Inflammatory pseudotumor is a nonneoplastic reactive pulmonary mass lesion that resembles tumor but shows little or no growth. Thc inflammatory pseudotufor usually present as a solitary round lung mass but in this casts progressed rapidly and destroyed the whole lung,which is rare. The patient was discharged with no problem and with outpatient followup.

A Case of Total Anomalous Pulmonary Venous Confluence in Adult Diagnosed by Echocardiography

Total anomalous pulmonary venous confluence(TAPC), a rare cyanotic congenital anomaly of the heart especially in adult, is now diagnosed by echocardiography instead of cardiac catheterization with high sensitivity and specificity. The key points are identification of pulmonary veins, pulmonary venous confluence draining anomalously to the heart. RVDVO on M-mode, abnormal echo free space posterior to left atrium on 2D-echo are basic characteristics of TAPVC. Peak velocity and flow profile measurement on the doppler provide additional informations : obstruction and anomalous vessels. A case of 23 year old male with supracardiac type TAPVC diagnosed by echocardiography was corrected successfully by surgery.