The 10 Years Experience of Lung Transplantation / 대한흉부외과학회지

BACKGROUND: Lung transplantation is a definitive therapy for a variety of end stage lung diseases. Since 1996, we have performed thirteen cases of lung transplantation including two retransplantations, and we analyzed the outcomes, complications, and survivals of these patients. MATERIAL AND METHOD: We retrospectively analyzed the medical records of thirteen cases from July, 1996 to July, 2005. RESULT: During the period, 11 patients had undergone 13 lung and heart-lung transplantations, and two patients had retransplantation due to allograft failure. Mean age of recipients were 45.2+/-10.7 years (range, 25~59). Early complications were bleeding, reperfusion injury, and infection and late complications were mainly infection and post-transplantation lymphoproliferative disease. Excluding the operative mortality, the mean survival period was 16.5 months (2~60 months). Two retransplantations had been performed 2 weeks and 13 months after single lung transplantations. CONCLUSION: In order to achieve long term survival, early detection of complications and proper treatment in addition to surgical skills are necessary, and these efforts can promote better lung transplantation programs in the near future.

New Trend of the Varicose Veins

Varicose vein is a very common vascular disease. The most common symptom is leg pain. Long-standing jobs, pregnancy, and a positive family history are the major ,redisposing or precipitating factors. The mainstay of treatnents includes compressive stocking, sclerotherapy, stab avulsion and stripping of vein, ligation of saphenofemorai juncion, transilluminated powered phlebectomy, VNUS, and eniovenous laser treatment.

Treatment of Vasodilatory Shock after Cardiac Surgery:Low Dose Arginine Vasopressin Therapy: Three cases report / 대한흉부외과학회지

The vasodilatory shock after cardiopulmonary bypass is defined as the condition involving severe and persistent form of hypotension, tachycardia, normal or increased cardiac output and decreased systemic vascular resistance. Because of the unsuccessful response to infusion of fluids or catecholamine vasopressors, a sustained systemic shock state occurs and results in a high morbidity and mortality. We successfully treated this syndrome of 3 patients after open heart surgery with low dose of arginine vasopressin(AVP). Therefore,we report these cases with a review of related articles.

Bilateral Sequential Single Lung Transplantation for Eisenmenger's Syndrome / 대한흉부외과학회지

Eisenmenger's syndrome is the disease of right to left shunt developing from the increased pulmonary vascular resistance caused by excessive pulmonary blood flow in patients with abnormal connections of systemic to pulmonary blood passage. The heart-lung transplantation was the only curative method in early transplantation period, but good results after bilateral lung transplantation have been reported as the fact that right heart function improved by only lung transplantation. We successfully carried out bilateral sequential single lung transplantation in a 34-year-old female patient with Eisenmenger's syndrome with large PDA. We report this case with a brief review of the literature.

Bilateral Sequential Single Lung Transplantation for Eisenmenger's Syndrome / 대한흉부외과학회지

Eisenmenger's syndrome is the disease of right to left shunt developing from the increased pulmonary vascular resistance caused by excessive pulmonary blood flow in patients with abnormal connections of systemic to pulmonary blood passage. The heart-lung transplantation was the only curative method in early transplantation period, but good results after bilateral lung transplantation have been reported as the fact that right heart function improved by only lung transplantation. We successfully carried out bilateral sequential single lung transplantation in a 34-year-old female patient with Eisenmenger's syndrome with large PDA. We report this case with a brief review of the literature.

Surgical Treatment of Varicose Vein - TIPP(Transilluminated Powered Phlebectomy / 대한흉부외과학회지

The present study was done to determine the efficacy and safety of varicose vein removal using a minimally invasive, powered vein-extracting device with cutaneous transillumination and tumescent anesthesia techniques and then compared this to a retrospective group of conventional phlebectomy operations. There were 133 limbs in 104 patients(72 women, 32 men) treated with the use of the vein extractor aided by transcutaneous illumination. The hydrodissection was performed with TrivexTM Irrigated Illuminator(Smith and Nephew ) system using normal saline after the 2~3mm sized skin incision. Varicose clusters were extracted by the use of TrivexTM Resector(Smith and Nephew ) system under transillumination. After the varisoce vein extraction, the operation area was compressed with surgical pad for bleeding control. The complication rate was 3.84%. The mean number of incisions was 3.24 and mean operative time per limb was 65.9 minutes. The mean hospitalization was 1.86 days. The varicose vein extraction using transilluminated powered phlebectomy(TIPP) is a safe, efficacious and cosmetically satisfactory method. The procedure decreases the operating time and the number of incisions repuired to remove varicose clusters. Further evaluation and long term follow up will be necessary to determine the recurrence rate and long term complications.

Sclerotherapy of the Varicose Veins / 대한흉부외과학회지

BACKGROUND: Sclerotherapy has been introduced as a new treatment modality of varicose vein. MATERIAL AND METHOD: Ninety-four patients with the diagnosis of varicose vein were treated with sclerotherapy at Yongdong Severance Hospital, Yonsei University Medical College from September, 1997 to August, 1999. History taking, physical examinations and laboratory examinations were performed. The short term outcome and the complications were reviewed. RESULT: The age of the patients were ranged from 20 to 70 years with the mean age of 43.4 years. All the patients(28 men, 66 women) had protruding superficial leg veins and 2 local pain, 2 fatigue, 1 heaviness. Complications were fever, phlebitis and ulceration. Fifty patients were satisfied after 1 procedure. CONCLUSION: Sclerotherapy is an effective treatment modality with cosmetic superiority for the patients with varicose veins.

Total Occlusion of Left Main Coronary Artery by Dilated Main Pulmonary Artery in a Patient with Severe Pulmonary Hypertension

A 34-year-old woman was admitted to the hospital because of recently aggravated right heart failure without angina for 5 months. When she was 25 years old, patch repair with Polytetrafluoroethylene (PTFE) was performed for the secondum type of atrial septal defect (ASD) with moderate pulmonary hypertension. The chest PA, echocardiography and cardiac catheterization at current admission revealed Eisenmenger syndrome without intracardiac shunt. Chest CT scan with contrast revealed markedly dilated pulmonary trunk, both pulmonary arteries and concave disfigurement of the left side of the ascending aorta suggesting extrinsic compression, as well as total occlusion of the ostium of the left main coronary artery that was retrogradly filled with collateral circulation from the right coronary artery. The coronary angiography showed normal right coronary artery and the collaterals that come out from the conus branch to the mid-left anterior descending artery (LAD) and that from distal right coronary artery to the left circumflex artery (LCX) and to the distal LAD, respectively. On aortography, the left main coronary artery was not visualized with no stump, suggestive of total occlusion of the ostium of the left main coronary artery. From our experience, it is possible to say that the occlusion of the ostium of the left main coronary can be induced by the dilated pulmonary artery trunk due to ASD with pulmonary hypertension and that, if the ASD closure was too late, the narrowing or obstruction of the left coronary artery could not be resolved even after operation owing to irreversible pulmonary hypertension.

Lung Transplantation in ABO Compatible but Nonidentical Patients / 대한흉부외과학회지

Lung transplantation in the treatment of end-stage emphysema has been increasing in number since the recent rise in the 5 year survival rate. For the shortage of donor lungs, the single lung transplantation or transplantation in ABO compatible, nonidentical recipients has also been increasing. The lung transplantation in compatible, nonidentical recipients show good results as with identical recipients with the proper application of immunosuppressive agents. We transplanted the left lung of a 41 year-old male donor to a 35 year-old female recipient who had been suffering from severe dyspnea due to end-stage emphysema. For postoperative immunosuppression, we applied conventional triple immunotherapy(cyclosporine, azathioprine, prednisolone) and we could suppress the rejection response of transplanted lung by adding the anti-CD3 antibody(OKT3) during the operation. The patient could be discharged without any specific problem at 18th postoperative day.

Lymphoproliferative Disease After Lung Transplantation in Transplanted Lung / 대한흉부외과학회지

The lymphoproliferative disease after the organ transplantation is more commonly seen with the increase according to the increasing number of the organ transplantations and it occurs more frequently in the cases of heart and lung transplantations that needs more aggressive immunosuppression. It demands urgent evaluation and management because of poor prognosis. We transplanted left lung of a man to the woman who suffered from severe dyspnea due to terminal pulmonary emphysema in discrepancy of ABO blood type. Postoperatively, We used triple regimen immunotherapy(cyclosporin, azathioprine, prednisolone) and followed up in the out patient clinic. During the follow up, we found abnormal mass lesion on the transplanted lung and performed gun biopsy. We confirmed malignant lymphoma on the pathologic examination and two cycled chemotherapy was given after reducing dose of immunosupression. The patient died of sudden onset of pulmonary edema of the transplanted lung.

Mesenchymal hamartomas of the chest wall in infancy: radiologic and pathologic correlation

Mesenchymal hamartoma of the chest wall is a rare tumor with about 53 reported cases in the English literature. We reviewed six chest wall mesenchymal hamartomas in four patients, including two cases with multiple lesions, with specific focus on the radiologic and pathologic correlation. All cases occurred in neonates or infants with ages ranging from seven hours to seven months. They were diagnosed with plain chest radiographs (n=6), ultrasonography (n=2), chest CT scan (n=6), whole body bone scan (n=2) and MRI (n=3). All cases except a small one without cystic change showed the typical features of mesenchymal hamartoma radiographically and pathologically. Radiologically they were well-circumscribed masses with solid and cystic components with multiple fluid-fluid levels in association with single or multiple rib destruction or change. The CT scan showed the typical findings of chest wall hamartoma, and the MR showed heterogeneous signal intensities of the mass on T1- and T2-weighted images. The MR also revealed more concisely a secondary aneurysmal bone cyst formation with multiple fluid-fluid levels on the T2-weighted image. Microscopically, they showed alternating areas of cartilaginous islands and primitive appearing mesenchymal proliferation, which corresponded well with the solid component on the radiologic findings. The areas of bone formation and blood-filled cystic spaces matched the calcified or ossified densities and the cystic components, respectively. A small case without cystic change showed peculiar radiological and pathological findings resembling an osteochondroma. In conclusion, mesenchymal hamartoma of the chest wall in infancy is quite rare and sometimes can be misdiagnosed as malignancy due to the bone-destroying radiographic appearance and the highly cellular and mitotically active microscopic features, unless the radiologists and pathologists are aware of the characteristic clinical, radiological, and pathological findings. Imaging studies can usually make a correct diagnosis with good correlation to the pathologic findings.

Right Single Lung Transplantation in Pulmonary Emphysema Patient: A report of case / 대한흉부외과학회지

Lung transplantation has been successfully employed for variety of obstructive lung disease. Single lung transplantation has become a therapeutic option for end-stage obstructive lung disease. The patient, a 57 year old man with emphysema, suffered from severe dyspnea, which progressively aggravated him for the last three years. A single lung transplantation was performed from a young brain-dead donor on April 7th, 1999 in the department of thoracic surgery, Respiratory Center, Yongdong Severance hospital, yonsei University. The immunosuppressive regimen was based on cyclosporine A and azathioprine from beginning, adding steroid. Single lung transplantation was feasible and beneficial in patients with end-stage emphysema.

Expression of osteopontin in calcified coronary atherosclerotic plaques

Advanced atherosclerosis is often associated with dystrophic calcification and remodeling of extracellular matrix of vascular wall. Recently many studies have documented a general relationship between calcification and severity of coronary disease, and discussed the feasibility of electron beam computed tomography for detecting and quantifying the coronary artery calcification in the patients. The present study investigated the expression and the localization of osteopontin, one of noncollagenous bone matrix protein, within the calcified coronary arteries. Autopsy-derived coronary artery specimens were scanned and reconstructed to visualize the pattern of coronary calcification using a novel microscopic computed tomography technique. The localization of the osteopontin were evaluated by immunohistochemial stain with LF7. The present study showed that the pattern of coronary calcification is variable and the expression of osteopontin is localized mainly to calcified lesion. The smooth muscle cells in addition to macrophage expressed osteopontin protein in human coronary atherosclerotic plaques. Soluble osteopontin released near to the sites of vascular calcification may represent an adaptive mechanism aimed at regulating the process of vascular calcification.

Coexpression of cyclooxygenase-2 and matrix metalloproteinases in human aortic atherosclerotic lesions

Inflammation appears to have a major role in the development of atherosclerosis. Cyclooxygenase-2 (COX-2) is involved in the inflammatory response via the generation of prostanoids that, in turn, are involved in the production of matrix metalloproteinases (MMPs). This study aimed to investigate atherosclerosis in human aortas for in situ tissue distribution of COX-2, MMPs including MMP-9 and membrane type 1 MMP (MT1-MMP), and tissue inhibitor of metalloproteinase-2 (TIMP-2). Immunohistochemical studies were performed on atherosclerotic lesions of aortas from patients with aortic aneurysms (n = 4) and dissections (n = 3) by using antibodies to COX-2, MMP-9, MT1-MMP, and TIMP-2. Control tissues were obtained from traumatically dissected aortas (n = 2). All specimens from diseased aortas had atherosclerotic lesions ranging from fatty streak to atheromatous plaques. In control, there was no expression of COX-2, MMP-9, and MT1-MMP in all aortic layers. Immunoreactivity for COX-2 was predominantly noted in macrophages and smooth muscle cells (SMCs) of the intima including atherosclerotic plaque itself and the medial layer of the plaque base, as well as in SMCs and endothelial lining of the vasa vasorum in the adventitia. Immunoreactivity for MMP-9 and MT1-MMP was found in the same distribution as that of COX-2. Additionally, the expression of TIMP-2 increased in relation to MMP-9 expression. This study demonstrates that COX-2 is coexpressed with MMP-9 and MT1-MMP, not only by macrophages and SMCs in atherosclerotic lesions, but also in endothelial lining of the vasa vasorum of human aortas. Thus, vascular inflammatory reactions may influence extracellular matrix remodeling by coactivation of MMPs in the development of atherosclerosis and, in turn, the progression of disease.

Underlying Etiologic Factor of Recurrent Pneumothorax after Bullectomy / 대한흉부외과학회지

BACKGROUND: The cause of spontaneous pneumothorax is not yet but it is certain that intrathoracic air comes from ruptured bulla. Video-assisted thoracoscopic surgery(VATS) or open thoracotomy is recommended for thoracic incision in recurrent pneumothorax. However, recurrent rate after bullectomy with the VATS is very high compared to mini-thoracotomy, 3% to 20% and below 2%, respectively. MATERIAL AND METHOD: This retrospective analysis was performed on 16 re-operated cases among 446 surgically treated pneumothorax of the 737 cases of spontaneous pneumothorax diagnosed at Yongdong Severance Hospital from Nov. 1992 to June 1997. RESULT: Among the 446 surgically-treated patients in 737 case of spontaneous pneumothorax, 16 patients underwent re-operation, showing a 3.5% re-operation rate. Male-to-female ratio was 15 to 1 and mean age at initial attack was 20.2 years(ranging from 15 to 50). Mean hospital stay was 6.34 days(ranging from 2 to 20 days) and mean chest tube indwelling period was 4.2 days(ranging from 1-10 days). Median follow-up was 46 months(range 10-66 months). Three different surgical methods were applied : video-assisted thoracoscopic surgery(VAST) in 281 cases, of whom 2 underwent local anesthesia; subaxillary mini-thoracotomy in 159 cases and limited lateral thoracotomy in the remaining 6 cases. Three different re-operative surgical methods were applied ; video-assisted thoracoscopic surgery (VAST) in 6 cases, subaxillary mini-thoracotomy in 9 cases, and limited lateral thoracotomy in the remaining 1 case. The underlying etiological factors of the recurrent pneumothorax after bullectomy were o erlooking type(9) and new growing type(7). Mean recurrent period from previous operation was 1 month for overlooking type and 18 months for new growing type. CONCLUSION: The underlying etiological factors of recurrent pneumothorax lead to re-operation were new-growing and over-looking type. We need additional treatments besides resecting blebs of prevent the recurrence rate and more gentle handling with forceps due to less damage to the pleura.

Intermuscular Hematoma in Esophagus: without Tearing / 대한흉부외과학회지

Spontanous hematoma of the esophagus is a rare condition affecting middle aged or elderly women. We experienced one case of esophageal hematoma which attracted our attention due to its confusing presentation clinically. The pathogenesis has been in dispute so far. The diagnosis has traditionally been made by barium esophagogram. We proved the diagnosis of spontaneous hematoma of the esophagus by utilizing CT scan and MRI. This condition led to conservative treatment and full recovery ultimately, but we performed the surgical correction because the filling defect persisted and the dysphagia got worse on the 20th day of hospital stay. Hematoma was located between the inner layer of circular muscle and the outer layer of longitudinal muscle which we considered as intermuscular hematoma of the esophagus.

Single Lung Transplantation in Pulmonary Fibrosis Patients / 대한이식학회지

A lung transplantation in the case of idiopathic pulmonary fibrosis was performed on July 7th, 1996 by the department of Thoracic Surgery, Yonsei University Medical College. The 52 year-old male patient (having a past history of cholecystectomy, 6 years ago) suffering from severe dyspnea, progressively aggravating for last five years. On physical examinations, two surgical scars were found in his left chest wall and upper abdominal area and wheezing was auscultated in both lung fields. The pulmonary function test performed in march, 1996, revealed FVC of 1940 ml (51%) and FEV1 of 1680 ml/min (58%) and the arterial blood gas study showed pH 7.4 PaO2 43.2 mmHg, PaCO2 35.0 mmHg (room air), pH 7.4 PaO2 89.8 mmHg, PaCO2 40.8 mmHg (mask 5l/min). Through the coronary angiography, moderate degree of pulmonary hypertension and 50% stenosis of left anterior descending branch of his coronary arteries were detected. The right lung from 17 year old male under brain death was removed through a median sternotomy incision and immersed in 70 ml/Kg of preservation solution (modified Euro-collins). Preparing the recipient, the pulmonary artery was dissected and temporally ligated for 15minutes, after then, an arterial blood gas study was taken to reveal pH 6.97, PaO2 221 mmHg, PaCO2 126 mmHg (FiO2 1.0 PEEP 5 cm) and his pulmonary arterial pressure was 85/26 mmHg (when the systemic arterial pressure was 140/80 mmHg) that indicates the necessity of the cardiopulmonary bypass; extracorporeal circulation was initiated through the femoral artery and right atrium. Placing the donor lung in the ipsilateral thoracic cavity of the recipient, the bronchus was first anastomosed in an telescopic fashion (the smaller bronchus into the lumen of the larger one) using the prolene 4-0. The pulmonary artery was anastomosed by prolene 5-0 and the LA by prolene 4-0. The total ischemic time was 70 minutes and the bypass time was 145 minutes. For the postoperative immunosuppression, cyclosporin and immuran was used and 2 weeks of induction therapy with OKT3 was followed by steroid. No evidence of rejection was shown in the transbronchial lung biopsy, performed a week after the transplantation. Fever developed 3 month after and aspergillosis and CMV infection was suspected through the transbronchial lung biopsy; vigorous treatment was followed but the patient had expired after 82 days postoperative survival.

Hyperhidrosis Treated by Thoracoscopic Sympathicotomy / 대한흉부외과학회지

BACKGROUND: Hyperhidrosis of the palms, axillae and face has a strong negative impact on social and professional life. The present existing non-operative therapeutic options seldom give sufficient relief and have a transient effect. A definitive cure can be obtained by upper thoracic sympathectomy. However, this is offset by the occurrence of a high rate of side effects, such as embarrassing compensatory sweating. MATERIAL AND METHOD: From Sep. 1997 to Feb. 1998, 89 cases of the needle(2 mm) thoracoscopic thoracic sympathicotomy were performed. The second thoracic ganglion was resected by cutting with a endoscissors. RESULT: A bilateral procedure takes less than 25 min and requires just one night in hospital. There have been no mortality or life-threatening complications. One patient(<2%) required intercostal drainage because of pneumothorax. Primary failure occurred in one cases(<2%) and recurrent hyperhidrosis occurred in no cases. The patients with failure was successfully re-sympathicotomy. At the end of postoperative follow-up(median 3 months), 96.6% of the patients were satisfied. Compensatory sweating occurred in 57 cases(64.0%) with fourteen of those cases classified as either embarrassing in 10 cases(11.2%) or disabling in 4 cases(4.5%). CONCLUSION: Endoscopic transthoracic sympathicotomy is an efficient, safe and minimally invasive surgical method for the treatment of palmar and craniofacial hyperhidrosis.

According to Extent of Sympathectomy, Compensatory Hyperhidrosis in Essential Hyperhidrosis / 대한흉부외과학회지

BACKGROUND: Since 1992, we developed the technique for video endoscopic sympathectomy to treat palmar hyperhidrosis. It was soon proven to be a simple and effective therapy for essential hyperhidrosis. Compensatory hyperhidrosis, however, is the main cause of patient dissatisfaction after video-assisted thoracoscopic sympathectomy. According to many authors, initial satisfaction rate was high(94-98%), but it was declined with time (66%) due to mainly to embarrassing side effects. MATERIAL AND METHOD: From January 1992 to February 1998, the thoracoscopic T2 sympathicotomy, T2 sympathectomy and T2-4 sympathectomy were performed in 315 patients suffering from Essential hyperhidrosis in the Department of Thoracic and Cardiovascular Surgery in the Respiratory Center of Yongdong Severance Hospital Seoul, Korea. Eighty-nine patients underwent T2 sympathicotomy, and Eighty-eight patients underwent division T2 sympathectomy. RESULT: All of the treated patients obtained satisfactory alleviation of essential hyperhidrosis. The global rate of compensatory sweating were ; 64.0% in T2 sympathicotomy, 73.8% in T2 sympathectomy and 87.8% in T2-4 sympathectomy. The rate of embarrassing or disabling compensatory sweating was significantly higher in T2 sympathicotomy 15.7%(14/89) and in T2 sympathectomy 32.8%(28/88) than in T2-4 sympathectomy 58.0%(80/138) with significancy in statistic analysis(p<0.05). Video- assisted thoracoscopic sympathectomy is an effective minimally invasive and effective procedure. CONCLUSION: We suggest that the incidence and degree of compensatory hyperhidrosis was closely related to the extent of thoracic sympathectomy.

Thoracic Trauma

No abstract available.