Risk Factors Associated with Difficult Reversal of Heparin by Protamine Sulfate in Cardiopulmonary Bypass: An Ignored Issue

Background@#The aim of this study was to evaluate risk factors associated with difficult heparin reversal by protamine after cardiopulmonary bypass. @*Methods@#Data from 120 consecutive patients who underwent open heart surgery from 2009 to 2017 were retrospectively reviewed. Patients were divided into 2 groups: (1) those in whom complete heparin reversal was achieved after a single infusion of protamine (group A, n=89); and (2) those who required more protamine for heparin reversal (group B, n=31). @*Results@#Female sex, prolonged bypass time (>200 min), long aortic cross-clamping time (>120 min), and a lowest rectal temperature <26°C were significant predictors of difficult heparin reversal. Larger amounts of fresh frozen plasma and platelet concentrate were transfused in group B than in group A. @*Conclusion@#Surgeons’ efforts to reduce operative time and avoid deep hypothermia may be helpful for increasing the likelihood of easy heparin reversal, especially in female patients.

Clinical Value of Intraoperative Flow Measurements of Brachiocephalic Arteriovenous Fistulas for Hemodialysis

Background@#The aim of this study was to analyze the clinical outcomes of autogenous brachiocephalic arteriovenous fistulas and to investigate the factors associated with 1-year patency after initiation of hemodialysis. @*Methods@#We retrospectively reviewed the medical records of 41 patients who underwent surgery to create an autogenous brachiocephalic arteriovenous fistula between January 2015 and December 2017, received hemodialysis at the same hospital for longer than 1 year, and were monitored for their vascular access status. Intraoperative flow was measured using transit-time ultrasonography. @*Results@#The 1-year primary and secondary patency rates were 61% (n=25) and 87.8% (n=36), respectively. The functional group (subjects who required no intervention to maintain patency within the first year after hemodialysis initiation) displayed a significantly higher median intraoperative flow rate (450 mL/min) than the non-functional group (subjects who required intervention at least once regardless of 1-year patency) (275 mL/min) (p=0.038). Based on a receiver operating characteristic curve analysis, all patients were additionally subdivided into a high-flow group (>240 mL/min) and a low-flow group (≤240 mL/min). The high-flow group included a significantly greater number of functional brachiocephalic arteriovenous fistulas than the low-flow group (74.2% vs. 20%, respectively; p=0.007). @*Conclusion@#Transit-time flow, as measured with intraoperative transit-time ultrasonography, was associated with patency without the need for intervention at 1 year after initiation of hemodialysis.

Cardiac Autotransplantation with Concurrent Pneumonectomy for Complete Resection of Primary Cardiac Intimal Sarcoma

Primary cardiac sarcoma is rare, and intimal sarcoma is an extremely rare and highly lethal disease. We report a case of a 62-year-old woman who was incidentally diagnosed with a primary cardiac sarcoma originating from the left atrial appendage and extending to the left superior pulmonary vein. The location of the tumor was very complicated, posing a major challenge for complete resection. We successfully performed complete resection of the cardiac sarcoma via cardiac autotransplantation with left pneumonectomy. The patient recovered uneventfully, without any adjuvant therapy as of 6 months postoperatively. Autotransplantation of the heart may be suggested as a reasonable surgical option for extensive left atrial tumors.

A Case of Pulmonary Embolism Caused by Huge Popliteal Venous Saccular Aneurysm

No abstract available.

Selective Shunting Based on Dual Monitoring with Electroencephalography and Stump Pressure for Carotid Endarterectomy

PURPOSE: The aim of this study is to analyze postoperative outcomes for carotid endarterectomy (CEA) in addition to the preoperative clinical characteristics related to selective shunting based on dual monitoring with stump pressure (SP) and electroencephalography (EEG). MATERIALS AND METHODS: We retrospectively reviewed medical records of 70 patients who underwent CEA from March 2010 to December 2017. CEA was performed under general anesthesia and selective shunting was done if the SP was lower than 35 mmHg regardless of EEG or if intraoperative EEG showed any changes different from preoperative one regardless of SP. RESULTS: There was no postoperative 30-day adjusted mortality or adverse cardiac events. Three patients (4.3%) had postoperative minor stroke finally reaching pre-operative neurologic status at the time of discharge. Twenty-six patients (37.1%) used shunting and severe contralateral internal carotid stenosis or occlusion was related to shunting (P < 0.010). There were larger number of symptomatic patients in shunt group in spite of no statistical significance (P=0.116). CONCLUSION: Perioperative stroke rate was 4.3% for CEA under general anesthesia based on dual intraoperative monitoring with SP and EEG. There was no 30-day adjusted mortality and adverse cardiac event. Severe stenosis or occlusion of contralateral internal carotid artery is related to shunting (P < 0.010).

Dual Monitoring with Stump Pressure and Electroencephalography During Carotid Endarterectomy

BACKGROUND: Intraoperative monitoring during carotid endarterectomy is crucial for cerebral protection. We investigated the results of carotid endarterectomy under dual monitoring with stump pressure and electroencephalography. METHODS: We retrospectively reviewed the medical records of 50 patients who underwent carotid endarterectomy between March 2010 and February 2016. We inserted a temporary shunt if the stump pressure was lower than 35 mm Hg or if any intraoperative change was observed on electroencephalography. RESULTS: Seventeen (34%) patients used a temporary shunt, and the mean stump pressure was 26.8 mm Hg in the shunt group and 46.5 mm Hg in the non-shunt group. No postoperative mortality or bleeding occurred. Postoperatively, there were 3 cases (6%) of minor stroke, all of which took place in the shunt group. A comparison of the preoperative and the intraoperative characteristics of the shunt group with those of the non-shunt group revealed no statistically significant difference between the 2 groups (p <0.01). CONCLUSION: Dual monitoring with stump pressure and electroencephalography was found to be a safe and reliable monitoring method with results comparable to those obtained using single monitoring. Further study should be performed to investigate the precise role of each monitoring method.

Unusual Presentation of a Cervical Mass Revealed as External Jugular Venous Aneurysm

Venous aneurysms of the jugular vein are one of the rare causes of neck swelling, and primary venous aneurysms of the external jugular vein are extremely rare. A 46-year-old woman presented with a painless and suddenly growing mass in the left neck. A computed tomography angiography revealed a fusiform venous aneurysm of the external jugular vein containing intraluminal thrombus. We performed resection of the aneurysm and ligation of the external jugular vein. Removal of the aneurysm of the neck vein was necessary because venous aneurysms with thrombosis may lead to serious thrombotic complications such as pulmonary embolism.

A Giant Popliteal Artery Aneurysm Treated with Exclusion and Bypass Using a Saphenous Vein

While popliteal artery aneurysm is the most common form of peripheral artery aneurysm, it is a rare condition in the general population. Furthermore, a giant popliteal artery aneurysm has not previously been reported in Korea. A 67-year-old male presented with left thigh pain that had begun 4 months earlier and was aggravated when in a sitting position. We found a giant aneurysm on the left popliteal artery and performed a bypass from the common femoral artery to the distal popliteal artery below the knee, using the autologous greater saphenous vein, and excluded the aneurysm at the sites of anastomoses.

Blood Transfusion in Brain Surgery: A Comparison of Elective versus Emergency Operations / 대한수혈학회지

BACKGROUND: Blood transfusion is often performed to support successful brain surgery. In this study, we looked at two groups of surgery patients to analyze the transfusion requirements for patients undergoing brain surgery in our hospital. Group A patients received elective surgery, whereby blood products were prepared in advance, and Group B patients required emergency surgery which is often accompanied massive bleeding, and therefore adequate transfusion blood may not be available in advance. METHODS: During a one year period, patients who received brain surgery were classified as requiring either elective (Group A) or emergency (Group B) surgery. In each group, operation time and blood transfusion requirements were compared. RESULTS: Of the 35 total patients included in this study, 14 cases were Group A and 21 cases were group B. Average operation time was 4 hours and 13 minutes (253 minutes), and 2 hours and 50 minutes (170 minutes), respectively for Groups A and B. Red Blood Cell (RBC) transfusion was conducted in more than 90% of all patients. Average volume of RBC transfusion per operation was 2.5 units (Group A) and 3.1 units (Group B). Fresh frozen plasma (FFP) was transfused in 21% of Group A patients and in 38% of Group B patients. Platelet Concentrate (PC) was transfused in 19% of Group B patients, only. CONCLUSION: FFP and PC were more frequently transfused in patients who received emergency surgery than those who received elective surgery. Preparation of, not only RBC, but FFP and PC is required for emergency brain surgery. Therefore, efforts to retain adequate amounts of blood are needed to support emergency brain surgery.

Calcifying Fibrous Pseudotumor of the Anterior Mediastinum

Calcifying fibrous pseudotumors are rare soft-tissue lesions pathologically characterized by hyalinized collagen, psammomatous or dystrophic calcification, and lympho-plasmacyte infiltration. They are clinically benign with an extremely low rate of recurrence and complete surgical resection is known to be the treatment of choice. We performed the resection of a calcifying fibrous pseudotumors in the anterior mediastinum without complications.

Calcifying Fibrous Pseudotumor of the Anterior Mediastinum

Calcifying fibrous pseudotumors are rare soft-tissue lesions pathologically characterized by hyalinized collagen, psammomatous or dystrophic calcification, and lympho-plasmacyte infiltration. They are clinically benign with an extremely low rate of recurrence and complete surgical resection is known to be the treatment of choice. We performed the resection of a calcifying fibrous pseudotumors in the anterior mediastinum without complications.

Expression of Matrix Metalloproteinase-2 and -13 and Tissue Inhibitor of Metalloproteinase-4 in Varicose Veins

BACKGROUND: The relationship between the degree of expression of matrix metalloproteinases or tissue inhibitor of metalloproteinases and venous reflux remains to be investigated. MATERIALS AND METHODS: Primary varicose vein tissues were obtained from 23 patients, 18 females and 5 males, aged from 19 to 73. Cephalic or basilic veins were obtained for the control group from 10 patients who underwent vascular access for maintenance hemodialysis. Two operative techniques (high ligation with stripping or endovenous laser coagulation) were used. The expression of matrix metalloproteinase-2 and 13 and tissue inhibitor of metalloproteinase-4 in the varicose vein group and control group was assessed semi-quantitatively by immunohistochemical slides stained with primary antibodies. RESULTS: Twenty (87%) of the varicose vein group patients had greater or lesser saphenous vein diseases with reflux. The focal weak (+) stain for matrix metalloproteinases-2, and 13, and tissue inhibitor of matrix metalloproteinase-4 was dominant in the varicose vein group; the focal or diffuse strong stain (++ or +++) was prevalent in the control group. The differences were statistically significant (p<0.01). The degree of reflux and the duration of symptoms were not significantly related to the expression of MMP-13 (p=0.317 and p=0.654, respectively). CONCLUSION: Further study should be performed to investigate the relationship between the clinical characteristics related to venous hypertension or reflux and expression of MMPs and TIMP in varicose veins.

Cystic Adventitial Disease of the Popliteal Artery: Resection and Repair with Autologous Vein Patch

Cystic adventitial disease is rare, but it is one of the well-recognized causes of non-atherosclerotic arterial stenosis or obstruction. Despite one of its most common symptoms being chronic intermittent claudication, it may be misdiagnosed as arterial embolism when presented with acute ischemic symptoms. Surgical resection is recommended because of recurrence or a low success rate with aspiration or endovascular stent. We performed resection and repair with autologous vein patch for cystic adventitial disease of the popliteal artery of a 57-year-old man presenting with pain, pallor, and paresthesia, without any postoperative complications or recurrence.

The Early Detection of Recurrence of Malignant Peripheral Nerve Sheath Tumor by Frequent Magnetic Resonance Imaging

Surgery has a key role in the treatment of malignant peripheral nerve sheath tumors (MPNSTs), but the resectability of paraspinal MPNSTs is only 20%. Therefore, spinal MPNSTs show frequent recurrence and poor prognosis. Local recurrence is much more common than metastasis for MPNSTs, and surgery still has a key role in the treatment of local recurrence. Therefore, it is important that recurrence must be detected before resectability is lost. However, no evidence-based follow-up protocol has been established for MPNST. The authors performed gross total resection in a 34-year-old woman presented with thoracic MPNST. Adjuvant radiotherapy and chemotherapy were not administered since these adjuvant therapies generally do not improve survival in MPNST and may cause additional neurovascular damage. Instead, the authors monitored the primary site every 3 months using magnetic resonance imaging to detect local recurrence at the earliest opportunity. The tumor recurred locally on two occasions without overt symptoms at 21 and 24 months postoperatively. These recurrences were treated successfully by gross total removal.

VATS Resection for a Posterior Mediastinal Extramedullary Hematopoietic Mass: Resection of Extramedullary Hematopoiesis / 대한흉부외과학회지

Extramedullary hematopoiesis is a common compensatory mechanism of chronic anemia, but an asymptomatic posterior mediastinal mass is rarely diagnosed as an extramedullary hematopoiesis after surgical resection. The differential from neurogenic tumors is important, but fine needle aspiration biopsy is not recommended because of the difficulty of approach and risk of bleeding. Although diagnosis and treatment can involve resection via thoracotomy, video-assisted thoracic surgery may also be a useful strategy. We performed video-assisted thoracic surgery on a 59-year-old man for posterior mediastinal extramedullary hematopoiesis, with no evidence of recurrence or related hematologic diseases.

Main Bronchial Reconstruction with Sparing of Pulmonary Parenchyma for Benign Diseases

Main bronchial reconstruction is anatomically suitable for benign main bronchial stenosis. But, it has been hardly recommended for operative mortality and morbidity. This study was aimed at providing validity and the proper clinical information of bronchoplasty for benign main bronchial stenosis by reviewing the results we obtained over the last ten years for main bronchial reconstruction operations. We retrospectively reviewed admission and office records. Twenty eight consecutive patients who underwent main bronchoplasty were included. Enrolled patients underwent main bronchial reconstruction for benign disease (tuberculosis in 21, trauma in 4, endobronchial mass in 3). Concomitant procedures with main stem bronchoplasty were performed in 19 patients. There were no incidences of postoperative mortality and significant morbidity. There were 2 cases of retained secretions, and these problems were resolved by bronchoscopy or intubation. All of the patients are still alive without obstructive airway problem. Bronchoplasty should be considered as one of the primary treatment modalities, if it is anatomically feasible.

Main Bronchial Reconstruction with Sparing of Pulmonary Parenchyma for Benign Diseases

Main bronchial reconstruction is anatomically suitable for benign main bronchial stenosis. But, it has been hardly recommended for operative mortality and morbidity. This study was aimed at providing validity and the proper clinical information of bronchoplasty for benign main bronchial stenosis by reviewing the results we obtained over the last ten years for main bronchial reconstruction operations. We retrospectively reviewed admission and office records. Twenty eight consecutive patients who underwent main bronchoplasty were included. Enrolled patients underwent main bronchial reconstruction for benign disease (tuberculosis in 21, trauma in 4, endobronchial mass in 3). Concomitant procedures with main stem bronchoplasty were performed in 19 patients. There were no incidences of postoperative mortality and significant morbidity. There were 2 cases of retained secretions, and these problems were resolved by bronchoscopy or intubation. All of the patients are still alive without obstructive airway problem. Bronchoplasty should be considered as one of the primary treatment modalities, if it is anatomically feasible.

Reconstruction of Mainstem Bronchus Obstructed by Endobronchial Tuberculosis / 대한흉부외과학회지

BACKGROUND: Non-invasive interventional therapy has been performed for main bronchial obstruction by endobronchial tuberculosis because of the risk of main bronchial reconstruction regardless of the pulmonary function. But, effects of the interventional therapy are attacked by arguments. This study was aimed at interpreting the risk and effectiveness of bronchoplasty for benign bronchial stenosis over the last ten years in our hospital by reviewing the results based on clinical progression. MATERIAL AND METHOD: We retrospectively reviewed the clinical records and out-patient medical records including 21 consecutive patients who underwent main bronchial reconstruction for obstruction by endobronchial tuberculosis. All of them had past medical history of anti-tuberculosis medication. They were preoperatively evaluated by bronchoscopy and chest computed tomography. RESULT: There were no incidences of postoperative mortality and significant morbidity. There were 2 cases of retained secretions but these problems were resolved by therapeutic bronchoscopy or intubation. All of the patients are still alive without obstructive airway problem. CONCLUSION: Bronchoplasty should be considered as one of the primary treatment modalities, if it is anatomically feasible.

Surgical Resection of Solitary Fibrous Tumors of the Pleura / 대한흉부외과학회지

BACKGROUND: Solitary fibrous tumors of the pleura (SFTP) is one of rare neoplasms that originated from submesothelial mesenchyme. Clinical course or extent of surgical resection is not well known. MATERIAL ANDMETHOD: We retrospectively reviewed all the clinical records of the patients who had undergone surgical resection of benign and malignant SFTP. RESULT: Twenty two (male : female 14 : 8) patients were enrolled and mean age was 50.2 (range 25~83). Number of symptomatic patients at the time of diagnosis was 13 (59%) and the most common symptom was dyspnea. Operative approach was carried out through thoracotomy (n=14) or video-assisted thoracic surgery (n=8). Mass excision was performed in 12 cases and en bloc resection including adjacent structure in 10 cases. In all cases complete resection was performed. There was no operative mortality. Malignant SFTP were 11 cases and benign SFTP 11 cases. Local recurrences (n=2) or distant metastasis (n=6) occurred only in malignant SFTP. CONCLUSION: Number of symptomatic patients, en bloc resection, and recurrence was more in malignant SFTP. Although complete surgical resection is known as treatment of choice for SFTP, further study should be performed about systemic therapeutic modalities pre- or postoperatively to control recurrence and metastasis.

Primary Giant Cell Tumor of Rib-Unusual Location / 대한흉부외과학회지

Giant cell tumor rarely occurs in ribs. Usually it is located in the posterior arc. We reported a very rare case of primary giant cell tumor of rib in the anterior arc with review of literatures.