A Prospective Randomized Trial Comparing Manual Needle Aspiration to Closed Thoracostomy as an Initial Treatment for the First Episode of Primary Spontaneous Pneumothorax / 대한흉부외과학회지

BACKGROUND: Variation exists in the initial treatment for the first episode of primary spontaneous pneumothorax (PSP), and no definitive consensus exists due to a lack of high-quality evidence. This study examined the outcomes of needle aspiration and closed thoracostomy in first episodes of PSP requiring intervention. METHODS: This study was a randomized, prospective, single-center trial conducted between December 2015 and August 2016. Patients of all ages with a documented first episode of PSP who were unilaterally affected, hemodynamically stable, and had a pneumothorax measuring over 25% in size were included. Patients with underlying lung disease, severe comorbidities, bilateral pneumothorax, tension pneumothorax, recurrent pneumothorax, traumatic pneumothorax, and pregnancy were excluded. Patients were randomly assigned to the needle aspiration or closed thoracostomy group using a random number table. RESULTS: Forty patients with a first episode of PSP were recruited, and 21 and 19 patients were included in the needle aspiration group and the closed thoracostomy group, respectively. The hospital stay of each group was 2.1±1.8 days and 5.4±3.6 days, respectively (p<0.01). However, no significant differences were found in the success rate of initial treatment or the 1-month and 1-year recurrence rates. CONCLUSION: Needle aspiration is a favorable initial treatment in patients experiencing a first episode of PSP.

A Prospective Randomized Trial Comparing Manual Needle Aspiration to Closed Thoracostomy as an Initial Treatment for the First Episode of Primary Spontaneous Pneumothorax

BACKGROUND@#Variation exists in the initial treatment for the first episode of primary spontaneous pneumothorax (PSP), and no definitive consensus exists due to a lack of high-quality evidence. This study examined the outcomes of needle aspiration and closed thoracostomy in first episodes of PSP requiring intervention.@*METHODS@#This study was a randomized, prospective, single-center trial conducted between December 2015 and August 2016. Patients of all ages with a documented first episode of PSP who were unilaterally affected, hemodynamically stable, and had a pneumothorax measuring over 25% in size were included. Patients with underlying lung disease, severe comorbidities, bilateral pneumothorax, tension pneumothorax, recurrent pneumothorax, traumatic pneumothorax, and pregnancy were excluded. Patients were randomly assigned to the needle aspiration or closed thoracostomy group using a random number table.@*RESULTS@#Forty patients with a first episode of PSP were recruited, and 21 and 19 patients were included in the needle aspiration group and the closed thoracostomy group, respectively. The hospital stay of each group was 2.1±1.8 days and 5.4±3.6 days, respectively (p<0.01). However, no significant differences were found in the success rate of initial treatment or the 1-month and 1-year recurrence rates.@*CONCLUSION@#Needle aspiration is a favorable initial treatment in patients experiencing a first episode of PSP.

Surgical Repair of Aortocaval Fistula Presenting with Cardiogenic Shock

Aortocaval fistula (ACF) occurs in < 1% of all abdominal aortic aneurysms (AAAs), and in 3% to 7% of all ruptured AAAs. The triad of clinical findings of AAA with ACF are abdominal pain, abdominal machinery bruit, and a pulsating abdominal mass. Other findings include pelvic venous hypertension (hematuria, oliguria, scrotal edema), lower-limb edema with or without arterial insufficiency or venous thrombus, shock, congestive heart failure, and cardiac arrest. Surgery is the main treatment modality. We report successful surgical treatment in a patient with a ruptured AAA with ACF who presented with cardiogenic shock.

Acute Limb Ischemia and Coronary Artery Disease in a Case of Kimura's Disease

Kimura disease (KD) is an immune-mediated chronic inflammatory disease of unknown etiology. KD has many complications associated with hypereosinophilia, including various forms of allergic reactions and eosinophilic lung disease. Additionally, hypereosinophilia is associated with hypercoagulability, which may lead to thromboembolic events. A 36-year-old man with KD presented with acute limb ischemia and coronary artery occlusion. He underwent thrombectomy, partial endarterectomy of both popliteal arteries, and coronary artery stent insertion. KD is a systemic disease that affects many organs and presents with thromboembolism and vasculitis. In a patient with KD, physicians should evaluate the vascular system, including the coronary arteries.

Feasibility and Safety of Single-Port Video-Assisted Thoracic Surgery for Primary Lung Cancer

BACKGROUND: The feasibility of single-port video-assisted thoracic surgery (SPVATS) for primary lung cancer is not well understood. In this study, we compared SP and multi-port (MP) VATS for the surgical treatment of patients with primary lung cancer. METHODS: Surgical treatment was performed in 181 patients with primary lung cancer at Inje University Haeundae Paik Hospital between June 2012 and December 2015. A propensity-matched analysis was used to compare the postoperative outcomes and to evaluate the comparative feasibility and safety of SPVATS and MPVATS. RESULTS: There were 37 patients in the SPVATS group and 67 patients in the MPVATS group. Propensity matching produced 32 pairs. The operation time (210 minutes versus 200 minutes, p=0.11), volume of the estimated blood loss (170 mL versus 160 mL, p=0.19), duration of chest tube drainage (5 days versus 6 days, p=0.66), and length of hospital stay (9 days versus 10 days, p=0.89) were similar between the 2 groups. CONCLUSION: In our study, SPVATS for primary lung cancer was safe and feasible in well selected patients. A prospective, randomized study with a large group and long-term follow-up is necessary to evaluate the clinical feasibility and the advantages of SPVATS for primary lung cancer.

A New Root-Strengthening Technique for Acute Aortic Dissection with a Weakened Aortic Root: The Neo-Adventitia Technique

BACKGROUND: Dissection flaps in acute type A aortic dissection typically extend into the root, most frequently into the non-coronary sinus (NCS). The weakened root can be susceptible not only to surgical trauma, but also to future dilatation because of its thinner layers. Herein, we describe a new technique that we named the “neo-adventitia” technique to strengthen the weakened aortic root. METHODS: From 2012 to 2016, 27 patients with acute type A aortic dissection underwent supracommissural graft replacement using our neo-adventitia technique. After we applied biologic glue between the dissected layers, we wrapped the entire NCS and the partial left and right coronary sinuses on the outside using a rectangular Dacron tube graft that served as neo-adventitia to reinforce the dissected weakened wall. Then, fixation with subannular stitches stabilized the annulus of the NCS. RESULTS: There were 4 cases of operative mortality, but all survivors were discharged with aortic regurgitation (AR) classified as mild or less. Follow-up echocardiograms were performed in 10 patients. Of these, 9 showed mild or less AR, and 1 had moderate AR without root dilatation. There were no significant differences in the size of the aortic annulus (p=0.57) or root (p=0.10) between before discharge and the last follow-up echocardiograms, and no reoperations on the aortic roots were required during the follow-up period. CONCLUSION: This technique is easy and efficient for reinforcing and stabilizing weakened roots. Furthermore, this technique may be an alternative for restoring and maintaining the geometry of the aortic root. An externally reinforced NCS could be expected to resist future dilatation.

Use of Extracorporeal Membrane Oxygenation in a Fulminant Course of Amniotic Fluid Embolism Syndrome Immediately after Cesarean Delivery / 대한중환자의학회지

Amniotic fluid embolism is rare but is one of the most catastrophic complications in the peripartum period. This syndrome is caused by a maternal anaphylactic reaction to the introduction of fetal material into the pulmonary circulation. When amniotic fluid embolism is suspected, the immediate application of extracorporeal mechanical circulatory support such as veno-arterial extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass should be considered. Without the application of extracorporeal mechanical circulatory support, medical supportive care might not be sufficient to maintain cardiopulmonary stabilization in severe cases of amniotic fluid embolism. In this report, we present the case of a 36-year-old pregnant woman who developed an amniotic fluid embolism immediately after a cesarean section. Her catastrophic event started with the sudden onset of severe hypoxia, followed by circulatory collapse within 8 minutes. The veno-arterial mode of extracorporeal membrane oxygenation was initiated immediately. She was successfully resuscitated but with impaired cognitive function. Thus, urgent ECMO should be considered when amniotic fluid embolism syndrome is suspected in patients presenting acute cardiopulmonary collapse.

Use of Extracorporeal Membrane Oxygenation in a Fulminant Course of Amniotic Fluid Embolism Syndrome Immediately after Cesarean Delivery / 대한구급학회지

Amniotic fluid embolism is rare but is one of the most catastrophic complications in the peripartum period. This syndrome is caused by a maternal anaphylactic reaction to the introduction of fetal material into the pulmonary circulation. When amniotic fluid embolism is suspected, the immediate application of extracorporeal mechanical circulatory support such as veno-arterial extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass should be considered. Without the application of extracorporeal mechanical circulatory support, medical supportive care might not be sufficient to maintain cardiopulmonary stabilization in severe cases of amniotic fluid embolism. In this report, we present the case of a 36-year-old pregnant woman who developed an amniotic fluid embolism immediately after a cesarean section. Her catastrophic event started with the sudden onset of severe hypoxia, followed by circulatory collapse within 8 minutes. The veno-arterial mode of extracorporeal membrane oxygenation was initiated immediately. She was successfully resuscitated but with impaired cognitive function. Thus, urgent ECMO should be considered when amniotic fluid embolism syndrome is suspected in patients presenting acute cardiopulmonary collapse.

Long Segmental Reconstruction of Diffusely Diseased Left Anterior Descending Coronary Artery Using Left Internal Thoracic Artery with Extensive Endarterectomy

In coronary artery bypass grafting, a diffusely diseased left anterior descending coronary artery (LAD) is an obstacle to achieving complete revascularization, consequently leading to the possibility of a poor prognosis. Long segmental reconstruction with or without endarterectomy is a revascularization method for treating diffusely diseased coronary arteries. Herein, we report a successful case of long segmental reconstruction of a diffusely diseased LAD using a left internal thoracic artery onlay patch after endarterectomy.

Early Outcomes of Single-Port Video-Assisted Thoracic Surgery for Primary Spontaneous Pneumothorax

BACKGROUND: Recently, single-port video-assisted thoracic surgery (VATS) has been proposed as an alternative to the conventional three-port VATS for primary spontaneous pneumothorax (PSP). The aim of this study is to evaluate the early outcomes of the single-port VATS for PSP. METHODS: VATS was performed for PSP in 52 patients from March 2012 to March 2013. We reviewed the medical records of these 52 patients, retrospectively. Nineteen patients underwent the conventional three-port VATS (three-port group) and 33 patients underwent the single-port VATS (single-port group). Both groups were compared according to the operation time, number of wedge resections, amount of chest tube drainage during the first 24 hours after surgery, length of chest tube drainage, length of hospital stay, postoperative pain score, and postoperative paresthesia. RESULTS: There was no difference in patient characteristics between the two groups. There was no difference in the number of wedge resections, operation time, or amount of drainage between the two groups. The mean lengths of chest tube drainage and hospital stay were shorter in the single-port group than in the three-port group. Further, there was less postoperative pain and paresthesia in the single-port group than in the three-port group. These differences were statistically significant. The mean size of the surgical wound was 2.10 cm (range, 1.6 to 3.0 cm) in the single-port group. CONCLUSION: Single-port VATS for PSP had many advantages in terms of the lengths of chest tube drainage and hospital stay, postoperative pain, and paresthesia. Single-port VATS is a feasible technique for PSP as an alternative to the conventional three-port VATS in well-selected patients.

Giant Cell Tumor Arising from Anterior Arc of the Rib

A primary giant cell tumor of the rib is very rare. The most common site of a giant cell tumor arising from the rib is the posterior arc. A giant cell tumor arising from the anterior arc of the rib is extremely rare. The treatment of a giant cell tumor of the rib is not well defined. Generally, a complete surgical resection is performed in a patient with a primary giant cell tumor of the rib. We report a case of a giant cell tumor arising from the anterior arc of the rib that was treated with a wide excision and chest wall reconstruction.

Single-port Video-Assisted Thoracic Surgery for Lung Cancer

Video-assisted thoracic surgery (VATS) is a minimally invasive technique that has many advantages in postoperative pain and recovery time. Because of its advantages, VATS is one of the surgical techniques widely used in patients with lung cancer. Most surgeons perform VATS for lung cancer with three or more incisions. As the technique of VATS has evolved, single-port VATS for lung cancer has been attempted and its advantages have been reported. We describe our experiences of VATS for lung cancer with a single incision in this report.

Stanford Type A Aortic Dissection Secondary to Infectious Aortitis: A Case Report

Nowadays, infectious aortitis has become a rare disease thanks to antibiotics, but remains life-threatening. We present a case of a patient with acupuncture-induced infectious aortitis leading to aortic dissection. Chest computed-tomogram scan revealed Stanford type A dissection with pericardial effusion. Under the impression of an impending rupture, emergent surgery was performed. During surgery, infectious aortitis was identified incidentally, so she underwent resection of the infected aorta including surrounding tissues. Then the ascending aorta and hemi-arch were replaced with a prosthetic graft as an in situ fashion. The resected tissue and blood cultures revealed Staphylococcus aureus, so prolonged antibiotherapy was prescribed.

An Unusual Case of Left Ventricular Free Wall Rupture Caused by a Silent Myocardial Infarction

Left ventricular free wall rupture (LVFWR) is a serious complication of myocardial infarction. It presents with a very high mortality rate and can be rescued by accurate diagnosis and emergency surgery. LVFWR can occur with sudden overt clinical symptoms or present insidiously. This report highlights the case of a man with no prior history of coronary artery disease, who presented with LVFWR and pericardial effusion that evolved to severe bacterial pericarditis.

Late Simultaneous Presentation of Left Ventricular Pseudoaneurysm and Tricuspid Regurgitation after Blunt Chest Trauma

A 32-yr-old man developed progressive exertional dyspnea 4 yr after blunt chest trauma due to an automobile accident. Two-dimensional echocardiography and computed-tomographic coronary angiography demonstrated a large pseudoaneurysm of the left ventricle and severe tricuspid regurgitation. The patient underwent successful surgical exclusion of the pseudoaneurysm by endoaneurysmal patch closure and repair of the tricuspid valve regurgitation. To the best of our knowledge, this is the first case of these 2 different pathologies presenting late simultaneously after blunt chest trauma and successful surgical repairs in the published literature.

Redo CABG Using Various Arterial Grafts / 대한흉부외과학회지

BACKGROUND: Although the reports on re-operative coronary revascularization (redo-CABG) have increased, there are only limited reports on redo-CABG using arterial grafts. The aim of this study was to analyze the safety and feasibility of using various arterial grafts for redo-CABG. MATERIAL AND METHOD: A consecutive series of patients who underwent 33 redo-CABGs from March 2001 to July 2008 were retrospectively reviewed. We performed conventional CABG in 17 patients, on-pump beating CABG in 7, off-pump CABG in 7 and minimally invasive direct coronary artery bypass in 2. The grafted that were used included 34 internal thoracic arteries (ITA), 14 radial arteries, 14 right gastroepiploic arteries and others. Arterial composite grafts were constructed in 26 patients. Of these, a previously patent in-situ left ITA was re-used as the in-flow of a composite graft in 10 patients. RESULT: No hospital deaths or major wound problems occurred. The post-operative complications included 2 myocardial infarctions (6%), 1 intra-aortic balloon pump insertion (3%), 5 cases of atrial fibrillation (15.1%) and 3 neurologic complications (9.1%). The mean follow-up duration was 31.1+/-22.7 months and the 3 year survival rate was 86.4%. There were 4 late deaths (2 cardiac deaths) and no recurrent angina during the follow-up period. CONCLUSION: Redo-CABG with using various arterial grafts is currently a safe, feasible procedure, but further investigation and long term follow-up are needed.

Surgical Treatment of Prosthetic Valve Endocarditis after Reconstruction of the Intervalvular Fibrous Trigon: A case report / 대한흉부외과학회지

We report here on a case of performing a redo-operation for a 65-years-old male patient who had prosthetic endocarditis after reconstruction of the fibrous skeleton due to infective endocarditis 8 years earlier. An aortic annular abscess with a 1 cm sized subvalvular abscess and mobile mitral valve vegetation with destruction of the fibrous skeleton was shown on the preoperative echocardiography. An emergency operation was performed due to heart failure. Reconstruction of both the aortic and mitral annuli and the fibrous skeleton was done by using two separate bovine pericardial patches and then mechanical valves were implanted. The postoperative echocardiography shows no paravalvular leakage. The patient has been followed up with no symptoms.

Closure of Atrial Septal Defects through a Video-assisted Mini-thoracotomy / 대한흉부외과학회지

BACKGROUND: Minimally invasive surgery is currently popular, but this has been applied very sparingly to cardiac surgery because of some limitations. Our study evaluated the safety and efficacy of atrial septal defect (ASD) closure through a video-assisted mini-thoracotomy. MATERIAL AND METHOD: Fifteen patients were analyzed. Their mean age was 31+/-6 years. The mean ASD size was 24+/-5 mm and there were 3 cases of significant tricuspid regurgitation. The working window was made through the right 4th intercostal space via a 4~5 cm inframammary skin incision. CPB was conducted with performing peripheral cannulation. After cardioplegic arrest, the ASDs were closed with a patch (n=11) or direct sutures (n=4), and the procedures were assisted by using a thoracoscope. There were 3 cases of tricuspid repair and 1 case of mitral valve repair. The mean CPB time and aortic occlusion time were 160+/-47 and 70+/-26 minutes, respectively. RESULT: There was no mortality, but there were 3 minor complications (one pneumothorax, one wound dehiscence and one arrhythmia). The mean hospital stay was 5.9+/-1.8 days. The mean follow-up duration was 10.7+/-6.4 months. The follow-up echocardiogram noted no residual ASD or significant tricuspid regurgitation. Three patients suffered from pain or numbness. CONCLUSION: This study showed satisfactory clinical and cosmetic results. Although the operative time is still too long, more experience and specialized equipment would make this technique a good option for treating ASD.

Mid-term Follow-Up Results of Cryopreserved Valved Conduit in RVOT Reconstruction / 대한흉부외과학회지

BACKGROUND: Since Ross and Sormeville first reported the use of aortic homograft valve for correction of pulmonary atresia in 1966, homograft valves are widely used in the repair of congenital anomalies as conduits between the pulmonary ventricle and pulmonary arteries. On the basis of these results, we have used it actively. In this report, we describe our experience with the use of cryopreserved valved homograft conduits for infants and children requiring right ventricle to pulmonary artery connection in various congenital cardiac anomalies. MATERIAL AND METHOD: Between January,1996 and December 2001, 27 infants or children with a median age of 16 months(range 9days to 18years) underwent repair of RVOTO using homograft valved conduit by two surgeons. We studied 22 patients who have been followed up at least more than one year. The diagnosis at operation included pulmonary atresia with ventricular septal defect (n=13), truncus arteriosus (n=3), TGA or corrected TGA with RVOTO (n=6). Homograft valved conduits varied in size from 15 to 26 mm (mean, 183.82 mm). The follow-up period ranged from 12 to 80.4 months (median, 48.4 months). RESULT: There was no re-operation due to graft failure itself. However, early progressive pulmonary homograft valve insufficiency developed in one patient, that was caused by dilatation secondary to the presence of residual distal pulmonary artery stenosis and hypoplasia after repair of pulmonary atresia with ventricular septal defect. This patient was required reoperation (conduit replacement). During follow-up period, there were significant pulmonary stenosis in one, and pulmonary regurgitation more than moderate degree in 3. And there were mild calcifications at distal anastomotic site in 2 patients. All the calcified homografts were aortic in origin. CONCLUSION: We observed that cryopreserved homograft conduits used in infant and children functioned satisfactorily in the pulmonic position at mid-term follow-up. To enhance the homograft function, ongoing investigation is required to re-establish the optimal strategy for the harvest, preservation and the use of it.

Surgical Results of Selected Stage IIIB Non-small Cell Lung Cancer / 대한흉부외과학회지

BACKGROUND: Traditionally, patients with stage IIIB non small cell lung cancer (NSCLC) have been considered inoperable due to the short-term survival rate of this disease. However, some recent papers have reported good surgical treatment results for T4 lesions in stage IIIB NSCLC. This study reports the results of stage IIIB NSCLC patients who underwent surgical treatment at our institute. MATERIAL AND METHOD: This study includes 109 patients who were diagnosed with pathological stage IIIA lung cancer and 59 patients who were diagnosed with pathological stage IIIB at our institute between 1994 to December 2001. Patients who underwent neo-adjuvant chemotherapy and radiation therapy were excluded from this study. According to the TNM classification, 13 patients from stage IIIA were classified into T3N1, 12 into T1N2, 73 into T2N2 and 11 into T3N2. Stage IIIB patients consisted of 26 patients with T4N0, 18 with T4N1, 14 with T4N2, and 1 with T4N3. RESULT: The 30-day mortality for stage IIIA and IIIB were 4.58% and 5.08% respectively. The overall survival rate at the 1st, 2nd, 3rd, and 5th year were 69.1%, 53.7%, 41.6%, and 30.7% respectively in stage IIIA and 68.8%, 55.6%, 42.9%, and 35.9% respectively in stage IIIB. Patients with satellite nodules in the same lobe& no lymph node involvement had a survival rate of 53.9% in 3 years compared with 15.2% in patients with satellite nodules in the same lobe with lymph node involvement. CONCLUSION: Surgical treatment is recommended for selected stage IIIB NSCLC patients (pathological N0 stage& completely resectable patients), particularly for patients with satellite nodules in the same lobe& no lymph node involvement.