The Clinical Outcome of Pulmonary Thromboendarterectomy for the Treatment of Chronic Pulmonary Thromboembolism / 대한흉부외과학회지

BACKGROUND: Diagnosing chronic pulmonary embolism at an early stage is difficult because of the patient's non-specific symptoms. This condition is not prevalent in Korea, and in fact, there have been only a few case reports on this in the Korean medical literature. We analyzed the surgical outcome of performing pulmonary thromboendarterectomy in patients with chronic pulmonary embolism. MATERIAL AND METHOD: The study subjects included those patients who underwent surgery for chronic pulmonary embolism from 1996 to 2008. For making the diagnosis, echocardiography, chest CT and a pulmonary perfusion scan were performed on the patients who complained of chronic dyspnea. RESULT: Pulmonary endarterectomy was performed as follows: by incision via a mid-sternal approach (7 patients); by incision via a left posterolateral approach (1 patient); using the deep hypothermic circulatory arrest technique (4 patients); under ventricular fibrillation (3 patients); and under cardioplegic arrest (1 patient). The postoperative systolic pulmonary artery blood pressure significantly decreased from a preoperative value of 78.9+/-14.5 mmHg to 45.6+/-17.6 mmHg postoperatively (p=0.000). The degree of tricuspid regurgitation was less than grade II after surgery. Two patients died early on, including one patient who had persistent pulmonary hypertension without improvement and right heart failure. CONCLUSION: Patients who have chronic pulmonary embolism are known to have a poor prognosis. However, we think that early surgical treatment along with making the proper diagnosis before the aggravation of right heart failure can help improve the quality of a patient's life.

Clinical Experience of the Surgical Treatment of Cardiac Tumor / 대한흉부외과학회지

BACKGROUND: Primary cardiac tumors are extremely rare. The most common type are benign myxomas, and these are almost completely curable with early surgery. Malignant tumors, however, such as sarcomas, are difficult to remove surgically, and their prognosis is known to be poor. In this study, data on patients who had undergone surgical treatment of cardiac tumor in the authors' hospital were collected and analyzed. MATERIAL AND METHOD: The subjects included 28 patients who had undergone surgical treatment of cardiac tumor from August 1993 to December 2008. Their medical records were reviewed and retrospectively analyzed. RESULT: The patients were aged from 20 to 76 years (mean age: 54.2+/-15.6), and 11 were male (39%) and 17 female (61%). Fifteen of them (54%) underwent emergency surgery to improve heart failure symptoms. The most common preoperative symptom was dyspnea (15 cases, 54%). Preoperative echocardiography was performed on all the patients. The average size of the tumor as measured during the operation was 7.0+/-6.9 cm (the average length of the long axis was 2~40 cm), and the sites of tumor attachment were the interatrial septum (18 cases, 64%), the left atrium (9 cases, 32%), the mitral valve annulus (2 cases, 7%), and the left ventricle (2 cases, 7%). The operation was performed with an incision through both atria in all the patients, and a complete excision was made in 25 cases (89%). According to the biopsy results, there were 4 cases of sarcoma (14%), 1 case of lipoma (4%), and 23 cases of myxoma (82%). The three cases in which the tumors were not completely excised were sarcomas. No operative deaths occurred after the operations. Outpatient follow-up was possible for 24 cases (86%), with a mean follow-up period of 46.8+/-42.7 months. Late death occurred in 3 of the 24 patients; each of these patients had sarcomas. Of these patients, the first had undergone two repeat surgeries, the second had metastatic sites removed, and the last had only chemotherapy. The average recurrence time was 12.7+/-10.8 months, and the average metastasis time was 20.5+/-16.8 months. CONCLUSION: Most cardiac tumors are benign myxomas. In principle, they should be surgically treated because they can create risks such as embolism, and can be radically treated when surgically removed. In most cases, however, malignant sarcomas are already considerably advanced with severe infiltration into the neighboring tissues at the time of diagnosis. The surgical removal of malignant sarcomas is known to be difficult because of the advanced stage and degree of infiltration. We suggest that excision of the removable portion of the tumor sites to alleviate symptoms such as heart failure can improve quality of life.

Obturator Bypass Surgery in a Patient with an Infected Femoral Artery Rupture after Performed ECMO: A case report / 대한흉부외과학회지

Infection of both native and prosthetic vessels in the groin is a very serious disease because of recurrent arterial rupture and sepsis, which can cause death. The successful treatment of groin infection, including infection of the femoral artery, requires extensive excision of the infected tissues and restoration of the circulation where the infected area is isolated. Here we describe a case of obturator bypass in a patient with infected femoral artery rupture that occurred after extracorporeal membrane oxygenation for myocarditis and severe heart failure.

Robot-assisted Thymectomy with the 'da Vinci' Surgical System in a Patient with Myasthenia Gravis: A case report / 대한흉부외과학회지

In the treatment of myasthenia gravis, thymectomy is generally accepted as the standard of therapy. For thymectomy, there have been various conventional open approaches including sternal splitting, but recently minimally invasive approaches have been increasingly applied. A 28-year-old man presenting with weakness of both hands and fatigability was diagnosed as having myasthenia gravis with thymic hyperplasia. He underwent a robot-assisted thymectomy with the 'da Vinci' surgical system. Through the right thoracic cavity, two thirds of the thymic gland was dissected, and the remainder was resected through the left; these procedures took, respectively, 1 hour and 30 minutes. The patient was discharged on the 8th postoperative day without complications. The minimally invasive approach with the 'da Vinci' surgical system is emerging as a popular choice and various advantages have been reported. Here we report the first successful case of robot-assisted thymectomy.

Repair of Ruptured Papillary Muscle of the Tricuspid Valve as a Cause of Tricuspid Insufficiency Following Blunt Chest Trauma / 대한흉부외과학회지

A 47-year-old man presented with complaints of chest pain and dyspnea caused by deceleration injury due to an automobile accident. Systolic cardiac murmur was audible at the right sternal border. An electrocardiogram showed sinus tachycardia. Transthoracic echocardiography revealed a flailing anterior leaflet of the tricuspid valve, papillary muscle rupture, and severe valve insufficiency. Rupture of papillary muscle of the anterior leaflet and chordae tendineae of the posterior leaflet were confirmed by right atrial incision under routine cardiopulmonary bypass. Artificial chordae tendineaes were implanted between the anterior and posterior leaflet and papillary muscles in the right ventricles. De-Vega annuloplasty was also added. This is a very rare case in which a surgery was done for tricuspid valve regurgitation caused by post-traumatic papillary muscle rupture.

Surgical Experience of Pericardial Mesothelioma: 2 Cases / 대한흉부외과학회지

Cardiac mesotheliomas are rare. It is difficult to diagnose them at an early stage because the symptoms are nonspecific. Here we report two cases that had been initially diagnosed as constrictive pericarditis but later were definitively diagnosed, after pericardiectomy, as mesothelioma. The two patients complained of dyspnea that lasted 4 months and 10 years. Chest CT showed mild pericardial effusion and thickened pericardium, which was found enveloping the heart without any lumps. Median sternotomy showed that the overall pericardium was thickened by more than 10 mm. Pericardiectomy (phrenic nerve to phrenic nerve) was performed and post-operative histology confirmed malignant mesothelioma. In one patient the disease recurred near the pericardium post-operatively at 7 months and the patient died at 11 months. The other patient received chemotherapy and was still alive at post-operative month 16. Pericardial mesothelioma is an extremely rare disease exhibiting clinical signs similar to those of constrictive pericarditis, and should be diagnosed at an early stage of onset.

da Vinci Robot-Assisted Esophagectomy for Esophageal Cancer: A Case of Esophago-gastrostomy through the Retrosternal Route : A case report / 대한흉부외과학회지

Operations using the da Vinci robot have performed in for many surgeries, but the adoption of robotics to general thoracic surgery has been slow. The patient (age 74, male) visited our hospital complaining of hiccups and dysphagia. The CT scan and endoscopic biopsy revealed esophageal cancer (squamous cell carcinoma). We performed transthoracic esophagectomy using a da Vinci robot and this was followed by gastric tube mobilization via laparoscopy. Cervical esophago-gastric anastomosis was done using the hand-sewn method. The gastric tube was brought into the neck through the retrosternal route. The patient was discharged without any complications. We report here on a case of successful da Vinci robotic esophgagectomy.

Independent Prognostic Value of the Fascin Expression in Patients with Esophageal Cancer / 대한흉부외과학회지

Backgrond: Fascin is an actin-bundling protein that induces membrane protrusions and it increases cell motility in various transformed cells. Esophageal cancer is one of the most lethal malignancies, and it exhibits extensive local invasion or frequent regional lymph node metastasis even after curative surgery. We investigate the expression of fascin by performing immunohistochemistry to evaluate the clinical characteristics and prognostic significance of its expression in esophageal cancer patients. MATERIAL AND METHOD: Immunochemistry for fascin was performed on 76 tumor samples from 76 patients who underwent esophageal cancer operations. The expression levels of fascin in the 76 esophageal cancer tissues were compared with those in the corresponding normal esophageal epithelium. The fascin-positive samples were defined as those showing more than 75% of fascin-positive cells. RESULT: Overall, a fascin positive expression was detected in 39 (51.3%) out of the total 76 cases. The tumors with positive fascin expression tended to more frequently show a higher stage (p=0.030), and a higher T-factor (p=0.031). The prognosis of the fascin negative group was significantly better than that of the fascin positive group (p=0.004). Multivariate analysis revealed that lymphovascular invasion and the fascin expression were independent prognostic factors. CONCLUSION: Fascin was expressed in 51.3% of the esophageal cancer tissues, and a positive expression of fascin was associated with more advanced tumor progression and recurrence. Our study suggests that the fascin expression may be an independent prognostic factor for an unfavorable clinical course for those patients suffering with esophageal cancer.

Comparison of the Mid-term Changes at the Remnant Distal Aorta after Aortic Arch Replacement or Ascending Aortic Replacement for Treating Type A Aortic Dissection / 대한흉부외과학회지

BACKGROUND: Replacing the ascending aorta is a standard surgical option for treating acute type A aortic dissection. But replacing the aortic arch has recently been reported as an acceptable procedure for this disease. We compared the effects of aortic arch replacement for treating acute type A aortic dissection with the effects of ascending aortic replacement. MATERIAL AND METHOD: From 2002 to 2006, 25 patients underwent surgical treatment for acute type A aortic dissection. 12 patients underwent ascending aortic replacement and 13 patients underwent aortic arch replacement. Among the aortic arch group, an additional distal stent-graft was inserted during the operation in 5 patients. 19 patients (11 arch replaced patients and 8 ascending aortic replaced patients) were followed up at the out patient clinic for an average of 756+/-373 days. All the patients underwent CT scanning and we analyzed their distal aortic segments. RESULT: 4 patients who underwent ascending aortic replacement died, so the overall mortality rate was 16%. Among the 11 long term followed-up arch replacement patients, 2 patients (18.1%) developed distal aortic dilatation and one of them underwent thoracoabdominal aortic replacement later on. However, among the 8 the ascending aortic replaced patients, 5 patients (62.5%) developed distal aortic dilatation. CONCLUSION: Aortic arch replacement is one of the safe options for treating acute type A aortic dissection. Aortic arch replacement for treating acute type A aortic dissection could contribute to a reduced distal aortic dilatation rate and fewer secondary aortic procedures.

Successful Surgical Treatment of Acute Mediastinitis after Central Catheter Insertion: One case report / 대한흉부외과학회지

Subclavian catheter insertion is now widely used because of its technical feasibility and effectiveness, but some complications related to this procedure have been noted. We present here a rare surgical case of post central line insertion mediastinitis with no mechanical complication.

A study for time sequential expression of IL-1 alphaand IL-6 after irradiation on rat lung / 대한내과학회지

BACKGROUND: One of the limitation during the irradiation of malignant tumor is hazard to normal tissue although it is important and effective tool for treating malignant tumor. We studied the role of interleukin-1 alpha (IL-1alpha) and interleukin-6 (IL-6) in the radiation-induced lung injury especially on fibrosis. METHODS: We irradiated right-side lungs of thirty Sprague-Dawley rats with single fraction of 20 Gy and then sacrificed the animals until 20th week at intervals of two weeks. Both irradiated and unirradiated lung tissues were stained hematoxilin and eosin, Masson trichrome, reticulin and immunohistochemical staining for IL-1alpha and IL-6. The degree of the staining for IL-1alpha and IL-6 were examined semiquantitatively. RESULTS: Two weeks after irradiation interstitial edema and capillary congestion appeared, followed by increase of the monocytes infiltration and proteinaceous material during 4th and 8th week. After eight weeks of irradiation, collagen and reticulin fibers were detected along alveolar wall. 12th to 20th week, fibrosis in interstitium, decreased number of alveoli and thickening of bronchial wall were observed. The degree of immunohistochemical staining for IL-1alpha and IL-6 was increased rapidly during the first three week and then decreased slowly, but remain incresed until 20th week. CONCLUSION: Our Study demonstrate the early and persistent elevation of cytokines IL-1alpha and IL-6 by immunohistochemical stain in rat lung following pulmonary irradiation. We think cytokines are produced immediately after irradiation, make collagen genes turn on and perisist until the expression of late effects become apparent pathologically and clinically.

Efficacy of Otolith Repositioning Maneuver and Its Clinical Features in Benign Paroxysmal Positional Vertigo

PURPOSE: Until recently, three variants of benign paroxysmal positional vertigo (BPPV) have been recognized: the first is posterior-canal canalolithiasis, the second is horizontal-canal canalolithiasis, and the last is horizontal-canal cupulolithiasis. However, the last two types of BPPV have not been introduced into the textbook of Emergency Medicine yet. The otolith repositioning maneuvers are effective treatments for BPPV, but in emergency medicine, there has been little interest in and research on them. Our goals were to determine the efficacies of these treatments and to examine the clinical features of each types of BPPV. METHODS: We performed a 6-month prospective study on forty-one patients (47 cases) who presented with a history and physical examination consistent with active BPPV to the emergency departments of a secondary hospital and a tertiary hospital (Dec. 2001-May. 2002). The patients were treated with a modified Epley canalith repositioning maneuver for posterior-canal BPPV, a modified Barbecue rotation for horizontal-canal canalolithiasis, and the maneuver of Jo et al. for horizontal-canal cupulolithiasis. RESULTS: A resolution attributable to the first intervention was obtained in 71.4% of the posterior-canal BPPV cases by using the modified Epley maneuver and in 73.1% of the horizontal-canal BPPV cases by using a modified Barbecue rotation and the maneuver of Jo et al. CONCLUSION: The otolith repositioning maneuvers result in a resolution of vertigo in the majority of patients (84.8% of the cases) immediately after treatment. They are safe and require no special equipment or investigations. They should be established as the treatments of choice for BPPV in emergency department.

The Clinical Experience of The Descending Thoracic and Thoracoabdominal Aortic Surgery / 대한흉부외과학회지

BACKGROUND: The thoracic and thoracoabdominal aortic surgery is a complicated procedure that has various method of approach and protection. The authors have performed several methods to treat these diseases. Therefore, we attempt to analyze their results and risks. MATERIAL AND METHOD: From June of 1992 to August of 2001, we performed 26 cases of thoracic aortic surgery and 10 cases of thoracoabdominal aortic surgery. There were 17 aortic dissections, 17 aortic aneurysms, one coarctation of aorta and one traumatic aortic aneurysm. The thoracic aortic replacement was performed under a femorofemoral bypass, an LA to femoral bypass, or a deep hypothermic circulatory arrest. The thoracoabdominal aortic replacement was performed under a femorofemoral bypass or a pump assisted rapid infusion. RESULT: There were 7 renal failures, 11 hepatopathies, 7 cerebral vascular accidents, 2 heart failures, 5 respiratory insufficiencies, and 2 sepsis in postoperative period. There were 9 hospital mortalities which were from 2 bleedings, 2 heart failures, 2 renal failures, a sepsis, a respiratory failure, and a cerebral infarction. There were 3 late deaths which were from ruptured distal anastomosis, cerebral infarction, and pneumonia. CONCLUSION: Deep hypothermic circulatory arrest was not good supportive methods for thoracic aortic replacement. Total thoracoabdominal aortic replacement was a high risk operation.

Imprint Cytologic Feature of Pleuropulmonary Blastoma: A Case Report / 대한세포병리학회지

Pleuropulmonary blastoma (PPB) is an unusual intrathoracic blastoma presenting in childhood and characterized by a biphasic neoplastic population of undifferentiated, small round blastemal cells and larger spindle-shaped sarcomatous cells with entrapped benign epithelial-lined structures. We experienced the cytologic features of PPB in imprint smear from the pleural-based huge mass of the middle lobe of the right lung in a 4-year-old boy. The smears showed high cellularity composed of small ovoid blastemal elements and scattered spindle mesenchymal tumor cells. Lobectomy and pathologic investigation confirmed the diagnosis. PPB seems to be a tumor in which accurate diagnosis may be achieved by cytology if appropriate clinical information were given. Timely and accurate diagnosis of PPB by cytology paves the way for attempting preoperative treatment in future cases.

The Study of Manometry and Gastric Emptying Time in Patients after Esophagectomy / 대한소화관운동학회지

BACKGROUND/AIMS: Resection of the esophagus for malignant disease or a benign stenosis, has a choice not only of palliative surgery, but also of replacement of the esophagus with a transposed stomach, jejunum, or colon. The first-line method is replacement with a tubulized stomach. The purpose of this study was to investigate the association of esophageal motor dysfunction and gastric emptying time with symptoms after esophagectomy. METHODS: We performed the esophageal manometry and gastric emptying time after esophagectomy for esophageal cancer in 12 patients and for benign esophageal disease in 2 patients. RESULTS: In manometric studies, a zone of high pressure in the esophago-gastric anastomosis distal to the upper esophageal sphincter was associated with symptoms after esophagectomy. The gastric emptying rate was slowed in 7 out of 14 patients, but not associated with symptoms after esophagectomy. CONCLUSIONS: Our data suggest that a high-pressure zone distal to the upper esophageal sphincter was associated with symptoms after esophagectomy in manometric study. The gastric emptying rate was not associated with postoperative symptoms.

The Results of Hyperfractionated Radiotherapy on Locally Advanced Non-Small Cell Lung Cancer / 대한방사선종양학회지

PURPOSE: The effect of hyperfractionated radiotherapy on locally advanced non-small lung cancer was studied by a retrospective analysis. MATERIALS AND METHODS: We analyzed sixty one patients of biopsy-confirmed, IIIA and IIIB non-small cell lung cancer. Using the ECOG performance scale, all the patients were scored less than 2. They were treated by curative hyperfractionated radiotherapy alone from Oct. 1992 to Oct. 1995 at the Department of Radiation Oncology. All the patients received 120cGy b.i.d with more than 6 hours interval between each fraction. The total dose of radiation was reached up to 6400-7080 cGy with a mean dose of 6934 cGy. The results were analyzed retrospectively. RESULTS: The overall survival rate was 53.1% in 1 year, 9.9% in 2 years with a median survival time (MST) of 13.9 months. The progression free survival (PFS) rate was 37.0% in 1 year, 8.9% in 2 years. Twenty two patients were classified as complete responders to this treatment and their MST was 19.5 months. When this was compared with that of partial responders (MST: 11.7months), it was statistically significant (p=0.0003). Twenty nine patients of stage IIIA showed a better overall survival rate (1yr 63.3%, 2yr 16.8%) than IIIB patients (1yr 43.3%, 2yr 3.6%), which was also statistically signifcant (p=0.003). Patients with adenocarcinoma showed a better survival rate (1yr 64.3%, 2yr 21.4%) than that of squamous cell counterpart (1yr 49.4%, 2yr 7.4%), although this was not significant statistically (p=0.61). Two patients developed fatal radiation-induced pneumonia right after the completion of the treatment which progressed rapidly and they all died within 2 months. One patient developed radiation-induced fibrosis after 13 months. He refused further treatment and died soon after the development of fibrosis. CONCLUSION: Among locally advanced NSCLC, hyperfractionated radiotherapy was effective on stage IIIA patients by increasing MST with acceptable toxicities. Acute radiation-induced pneumonia should be carefully monitored and must be avoided during or after this treatment.

Right Pulmonary Artery Originating Form Ascending Aorta: A Report of Case / 대한흉부외과학회지

The anomaly which the right pulmonary artery originates from the ascending aorta is a rare and usually fatal form of congenital heart disease. This lesion is often associated with a patent ductus arteriosus. Death frequently occurs in early infancy. Anomalous origin of the right pulmonary artery is much more common than anomalous origin of the left pulmonary artery. The anomalous right pulmonary artery usually arise from the posterior aspect of the ascending aorta close to the aortic valve. We report a 1 month-old infant with right pulmonary artery arising from the ascending aorta, which was corrected successfully by direct anastomosis to the main pulmonary artery.

Intracardiac a Aortic Foreign Body / 대한흉부외과학회지

A 50-year-old male patient was admitted due to right ventricular and aortic foreign bodies with ascending aortic pseudoaneurysm. The patient had a history of Kirschner wire fixation of right sternoclavicular joint 3 months ago. Under cardiopulmonary bypass, two K-wires were removed and injured pulmonary valve leaflet and aortic wall were repaired successfully. The postoperative course was uneventful and the patient was discharged on the 14th postoperative day.

Large aspergilloma cavity treated by Cavernostomy and ometal, muscle flaps: A case report / 대한흉부외과학회지

Pulmonary aspergilloma is potentially a life threatening disease resulting from the colonization of lung cavities by Aspergillus fumigatus. A case is reported: a 43-year-old man with symtomatic cavitary aspergilloma presenting with severe productive coughing, hemoptysis, occasional fever, and chilling. On preoperative plain chest radiograph and CT scan, we could find a rounded irregular opacity in a large pulmonary cavity. He received 2 separate operations for therapeutic need. At the first opertion, we performed cavernostomy and thoracoplasty because of severe pleural adhesions, tearing of cavity wall, and high risk of respiratory insufficiency. At the second operation, we performed myoplasty and omentoplasty for closure of remaining air space and complete wrapping of the BPF site. All symptoms of dyspnea and hemoptysis have since resolved. We believed that in the high risk patients who have severe respiratory symptoms, such as in aspergilloma and open cavity with a risk of respiratory insufficiency, cavernostomy followed by myoplasty or omentoplasty should be recommended.

Both Carotid Endarterectomy in Obstrution of Carotid Arteries and Bypass Graft with Kidney Preservation in Obstrution of Abdominal Aorta: A Report of Case / 대한흉부외과학회지

A 56 years old male patient admitted to our neurology department because of repeated tingling sensation in right 3, 4, 5th. fingers and weakness on grasping, which were progressively developed recently. At this time, he had also suffered from claudication in both lower extremities. Carotid angiogram showed that right internal carotid artery was obstructed completely, and both common, both external and left internal carotid arteries had significant stenosis, Concommitantly, aortogram suggested complete obstruction just below the renal arteries. We planned staged operation for two separated arterial lesions. Both carotid endarterectomy was performed. and we used carotid shunt for left side during operation. Abdominal aortic lesion was operated 2 weeks later. We obligately clamped aorta just below the celiac artery and infused kidney perservation solution to pertect kidney during ischemia. Reversed Y bypass graft and kidney perservation was successful despite of 40 minute ischemia. Postoperative coure was uneventful and patient was discharged without any specific problem.