Various Treatment Modalities in Hepatic Hydrothorax: What Is Safe and Effective?

PURPOSE: Hepatic hydrothorax is a complication of decompensated liver cirrhosis that is difficult and complex to manage. Data concerning the optimal treatment method, other than liver transplantation, are limited. This study aimed to compare the clinical features and outcomes of patients treated with various modalities, while focusing on surgical management and pigtail drainage. MATERIALS AND METHODS: Forty-one patients diagnosed with refractory hepatic hydrothorax between January 2013 and December 2017 were enrolled. RESULTS: The mean Child-Turcotte-Pugh and model for end stage liver disease scores of the enrolled patients were 10.1 and 19.7, respectively. The patients underwent four modalities: serial thoracentesis (n=11, 26.8%), pigtail drainage (n=16, 39.0%), surgery (n=10, 24.4%), and liver transplantation (n=4, 9.8%); 12-month mortality rate/median survival duration was 18.2%/868 days, 87.5%/79 days, 70%/179 days, and 0%/601.5 days, respectively. Regarding the management of refractory hepatic hydrothorax, surgery group required less frequent needle puncture (23.5 times in pigtail group vs. 9.3 times in surgery group), had a lower occurrence of hepatorenal syndrome (50% vs. 30%), and had a non-inferior cumulative overall survival (402.1 days vs. 221.7 days) compared to pigtail group. On multivariate analysis for poor survival, body mass index 10, and history of severe encephalopathy (grade >2) were associated with poor survival. CONCLUSION: Serial thoracentesis may be recommended for management of hepatic hydrothorax and surgical management can be a useful option in patients with refractory hepatic hydrothorax, alternative to pigtail drainage.

Nosocomial Infection in Adult Patients Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation

Data on the frequency of nosocomial infections during extracorporeal membrane oxygenation (ECMO) in adult populations remain scarce. We investigated the risk factors for nosocomial infections in adult patients undergoing venoarterial ECMO (VA-ECMO) support. From January 2011 to December 2015, a total of 259 patients underwent ECMO. Of these, patients aged 17 years or less and patients undergoing ECMO for less than 48 hours were excluded. Of these, 61 patients diagnosed with cardiogenic shock were evaluated. Mean patient age was 60.6 ± 14.3 years and 21 (34.4%) patients were female. The mean preoperative Sequential Organ Failure Assessment (SOFA) score was 8.6 ± 2.2. The mean duration of ECMO support was 6.8 ± 7.4 days. The rates of successful ECMO weaning and survival to discharge were 44.3% and 31.1%, respectively. There were 18 nosocomial infections in 14 (23.0%) patients. These included respiratory tract infections in 9 cases and bloodstream infections in a further 9. In multivariate analysis, independent predictors of infection during ECMO were the preoperative creatinine level (hazard ratio [HR], 2.176; 95% confidence interval [CI], 1.065–4.447; P = 0.033) and the duration of ECMO support (HR, 1.400; 95% CI, 1.081–1.815; P = 0.011). A higher preoperative creatinine level and an extended duration of ECMO support are risk factors for infection. Therefore, to avoid the development of nosocomial infections, strategies to shorten the length of ECMO support should be applied whenever possible.

Prediction of Intimal Tear Site by Computed Tomography in Acute Aortic Dissection Type A

BACKGROUND AND OBJECTIVES: Preoperative identification of intimal tear site in acute type A dissection will help procedural planning. The objective of this study was to determine the key findings of computed tomography (CT)-based prediction for tear site and compare the accuracy between radiologists and surgeons. SUBJECTS AND METHODS: Multi-detector CT (MDCT) images from 50 patients who underwent surgical repair of type A aortic dissection were retrospectively reviewed by 4 cardiac surgeons with limited experience or by 3 radiologists specialized in cardiovascular imaging. Surgical findings of intimal tear site were used as references. RESULTS: In surgical findings, the locations of intimal tear that were identified in 43 patients included aorta (n=25), ascending with arch (n=7), and arch only (n=11). The rest were retrograde dissections from the tear of descending aorta. Key CT findings that were most frequently found were defect in the intimal flap shadow (30.0+/-4.0 patients/reviewer, accuracy 87.0+/-11.7%) and differential filling of false lumen by phase and location (9.4+/-2.9 patients/reviewer, 84.8+/-10.4%). Surgeons predicted tear site (75.0+/-7.7% vs. 86.7+/-1.2%, p=0.055) and specified flap defect (80.5+/-10.3% vs. 95.7+/-7.4%, p=0.073) with lower accuracy than radiologists. CONCLUSIONS: With MDCT imaging, well-educated surgeons could be accurate in three fourths of cases. There was room for improvement through experience. Considering the substantial possibility of inaccuracy, critical decisions on CT images should be made through thorough reviewing by as many experienced radiologists and surgeons as possible.

Retrospective Analysis of Thoracoscopic Surgery for Esophageal Submucosal Tumors

BACKGROUND: Surgical enucleation is the treatment of choice for esophageal submucosal tumors (SMTs) with symptomatic, larger, or ill-defined lesions. The enucleation of SMTs has traditionally been performed via thoracotomy. However, minimally invasive approaches have recently been introduced and successfully applied. In this study, we present our experiences with the thoracotomic and thoracoscopic approaches to treating SMTs. METHODS: We retrospectively reviewed 53 patients with SMTs who underwent surgical enucleation between August 1996 and July 2013. Demographic and clinical features, tumor-related factors, the surgical approach, and outcomes were analyzed. RESULTS: There were 36 males (67.9%) and 17 females (32.1%); the mean age was 49.2+/-11.8 years (range, 16 to 79 years). Histology revealed leiomyoma in 51 patients, a gastrointestinal stromal tumor in one patient, and schwannoma in one patient. Eighteen patients (34.0%) were symptomatic. Fourteen patients underwent a planned thoracotomic enucleation. Of the 39 patients for whom a thoracoscopic approach was planned, six patients required conversion to thoracotomy because of overly small tumors or poor visualization in five patients and accidental mucosal injury in one patient. No mortality or major postoperative complications occurred. Compared to thoracotomy, the thoracoscopic approach had a slightly shorter operation time, but this difference was not statistically significant (120.0+/-45.6 minutes vs. 161.5+/-71.1 minutes, p=0.08). A significant difference was found in the length of the hospital stay (9.0+/-3.2 days vs. 16.5+/-5.4 days, p<0.001). CONCLUSION: The thoracoscopic enucleation of submucosal esophageal tumors is safe and is associated with a shorter length of hospital stay compared to thoracotomic approaches.

Diffuse Large B-cell Lymphoma Arising from Chronic Tuberculous Empyema

Pyothorax-associated lymphoma is a relatively rare type of lymphoma that occurs in patients who have long histories of tuberculous pleuritis or induced pneumothorax. It is a type of non-Hodgkin's lymphoma of mainly the B-cell phenotype and is strongly associated with Epstein-Barr virus infection. A majority of these cases have been reported in Japan, although some cases have occurred in Western countries. Here, we describe a case of pyothorax-associated lymphoma in a patient with a 30-year history of chronic tuberculous empyema. The patient underwent decortication under the impression of chronic empyema with fistula. The histopathologic diagnosis was a diffuse large B-cell lymphoma associated chronic inflammation.

Prognosis in the Patients with Prolonged Extracorporeal Membrane Oxygenation

BACKGROUND: Prolonged usage of extracorporeal membrane oxygenation (ECMO) may induce multi-organ failure. This study is aimed to evaluate prognostic factors in the patients with ECMO. Also, the prognosis of ECMO with Kidney Injury Network Scoring system is studied. MATERIALS AND METHODS: From May 2005 to July 2011, 172 cases of ECMO were performed. The cases of perioperative use of ECMO were excluded. Renal failure patient and younger than 15 years old one were also excluded. As a result, 26 cases were enrolled in this study. Male patients were 15 (57.7%), and mean age was 56.57+/-17.03 years old. Demographic data, ECMO parameters, weaning from ECMO, and application of continuous renal replacement therapy are collected and Acute Kidney Injury Network (AKIN) scores were evaluated just before ECMO and day 1, day 2 during application of ECMO. RESULTS: Venoarterial ECMO was applied in 22 cases (84.6%). The reasons for applications of ECMO were cardiac origin in 21 (80.8%), acute respiratory distress syndrome in 4, and septic shock in 1 case. Successful weaning from ECMO was achieved in 15 cases (57.7%), and survival discharge rate was 9 cases (34.6%). Mean duration of application of ECMO was 111.39+/-54.06 hours. In univariate analysis, myocarditis was independent risk factors on weaning failure. Using the receiver operating characteristic curve, level of hemoglobin on 24 hours after ECMO, and base excess on 48 hours after ECMO were showed more than 0.7. AKIN score was not matched the prognosis of the patients with ECMO. CONCLUSION: In our study, the prognosis of the patients with myocarditis was poor. Hemoglobin level at first 24 hours, and degree of acidosis at 48 hours were useful methods in relating with prognosis of ECMO. AKIN scoring system was not related with the prognosis of the patients. Further study for prognosis and organ injury during application ECMO may be needed.

Post-Infarction Ventricular Septal Rupture: 10 Years of Experience / 대한흉부외과학회지

BACKGROUND: Postinfarction ventricular septal rupture is associated with mortality as high as 85~90%, if it is treated medically. This report documents our experience with postinfarction ventricular septal rupture that was treated surgically. MATERIAL AND METHOD: We retrospectively reviewed the medical records of 11 patients who were operated on due to postinfarction ventricular septal rupture between August 1996 and August 2006. There were 4 men and 7 women, with a mean age of 70+/-11 years (age range: 50~84 years). The location of the rupture was anterior in 7 cases and posterior in 4 cases. The interval between the onset of acute myocardial infarction and the occurrence of the ventricular septal rupture was 2.0+/-1.3 days (range: 1~5 days). Operation was performed at an average of 2.4+/-2.7 days (range: 0~8 days) after the diagnosis of septal rupture. Preoperative intraaortic balloon pump therapy was performed in 10 patients. RESULT: The infarct exclusion technique was used in all cases. Coronary artery bypass grafting was done in 8 cases, with the mean number of distal anastomosis being 1.0+/-0.8. There was one operative death. In 2 patients, reoperation was performed due to a residual septal defect. The postoperative morbidities were transient atrial fibrillation (n=7), paroxysmal supraventricular tachycardia (n=1), low cardiac output syndrome (n=3), bleeding reoperation (n=2), delayed sternal closure (n=2), acute renal failure (n=2), pneumonia (n=1), intraaortic balloon pump-related thromboembolism (n=1), and transient delirium (n=2). Nine patients have been followed up for a mean of 38+/-40 months except for one follow-up loss. There have been 3 late deaths. At the latest follow-up, all 6 survivors were in a good functional class. CONCLUSION: We demonstrated satisfactory operative and midterm results with our strategy of preoperative intraaortic balloon pump therapy, early repair of septal rupture by infarct exclusion and combined coronary revascularization.