[Combined Resection of the Aorta under Cardiopulmonary Bypass for Locally Advanced Lung Cancer].

We present two cases with locally advanced lung cancer invading the descending aorta. Case 1 is a 67 years old male, who had been followed up for stroke. Enlargement of a mass lesion in the left lung was pointed out on further examination. Case 2 is a 64-year-old man, who was referred to our hospital because of cough and abnormal shadow on the chest X-ray and computed tomography (CT). We suspected that both tumors were lung carcinoma invading the descending aorta based on enhanced CT findings. In both cases, the clinical stage was cT4N0M0 stageⅢA. They underwent left pneumonectomy with combined en bloc tubular resection and reconstruction of the descending aorta via a posterolateral thoracotomy using cardiopulmonary bypass in the right lateral decubitus position. The histologic type of both tumors was squamous cell carcinoma. The pathological staging was pT4N0M0 in case 1, and pT4N2M0 in case 2. After surgery, the first patient received chemotherapy consisting of carboplatin and vinorelbine plus pembrolizumab. He survived 17 months until sudden death of unknown reason. The second did not receive adjuvant treatment because his postoperative performance status was slightly reduced. He died of local recurrence 6 months after the operation.

[Papillary Thyroid Cancer Metastasizing Anterior Mediastinal Lymph Node with Extra-nodal Invasion to the Lung:Report of a Case].

We describe a 79-year-old female with a prior history of two times of mitral valve surgery and pacemaker implantation. She was transferred to our hospital presenting bloody sputum with dyspnea. Chest enhanced computed tomography (CT) showed a large anterior mediastinal mass of 64×52 mm in size. She underwent surgery for the mediastinal tumor through third time median sternotomy approach. As the tumor was suspected of infiltrating to the lung, combined resection of right upper lobe was additionally performed. Histological examination revealed papillary thyroid carcinoma metastasizing anterior mediastinal lymph node with extra-nodal invasion to the lung. After surgery, echography detected primary lesion in the left lobe of thyroid gland, and the patient was finally diagnosed as papillary thyroid cancer metastasizing mediastinal lymph node. Two months later, she underwent total thyroidectomy.

[Superior Vena Cava Syndrome due to Large Cell Neuroendocrine Carcinoma Originated in the Mediastinum].

We report a case of a 53-year-old man with superior vena cava( SVC) syndrome due to large cell neuroendocrine carcinoma (LCNEC) in the mediastinum. His chief complaint was general fatigue. On physical examination, both jugular veins were distended and his face and bilateral upper limbs were swollen. Enhanced chest computed tomography (CT) scan demonstrated a heterogenous tumor of approximately 50 mm in diameter in the middle mediastinum, which infiltrated into the SVC and right atrium, and caused SVC syndrome. Since SVC syndrome developed rapidly, the tumor was resected and the occluded SVC was replaced with a ringed polytetrafluoroethylene graft under cardiopulmonary bypass. After surgery, SVC obstruction was resolved with improvement of the initial symptoms. The patient had an uneventful recovery and was discharged from our hospital. The tumor was diagnosed as LCNEC histologically. He received postoperative adjuvant systemic chemotherapy. Unfortunately, he died of extensive brain and bone metastasis 10 months after the operation. However, we believe that surgical relief from SVC syndrome improved quality of the rest of his life.

Successful treatment of a right internal mammary artery aneurysm with thoracoscopic surgery.

Internal mammary artery aneurysms are rarely detected, with only a few cases caused by physical trauma, connective tissue diseases, and vasculitis having been reported. We describe the case of a 52-year-old woman diagnosed with a right internal mammary artery aneurysm several months after experiencing a DeBakey Ⅲ acute aortic dissection. The artery had an indication of dissection that seemed to have caused the aneurysm. Thoracoscopic resection was performed, and the patient recovered with no major complications.

Renal Vein Thrombosis After Open Repair of Abdominal Aortic Aneurysm Successfully Treated by Direct Oral Anticoagulants.

INTRODUCTION: Venous thromboembolism (VTE) of the lower extremities frequently occurs after surgery. It is unknown whether the complication of renal vein thrombosis (RVT) develops after an open repair (OR) for abdominal aortic aneurysm (AAA). Furthermore, anticoagulation therapy with apixaban, a direct oral anticoagulant (DOAC), has not been described as treatment for RVT in such cases. CASE: A 64-year-old man underwent OR for AAA. Postoperative computed tomography revealed RVT in the left renal vein. Apixaban (5 mg twice a day) therapy was initiated. Six months later, we discontinued anticoagulation therapy and observed no recurrence. Following OR, our patient developed RVT for which DOACs were very useful. CONCLUSION: Thus, RVT can manifest as VTE after OR and direct anticoagulants can be considered as a therapeutic option.

[Empyema Successfully Treated by Plombage with Abdominal Rectus Muscle and Omental Flap after Open-window Thoracostomy;Report of a Case].

The partient was 76-year-old male. He had acute empyema due to lung abscess and open-window thoracotomy was performed to control infection. 3 years and 9 months later, the bronchial fistula was closed with abdominal rectus muscle and greater omentum. These are very useful when other muscles such as latissimus dorsi muscle, serratus anterior muscle and pectoralis major muscle are not available.

Effective kissing stent to severe stenosis of the superior mesenteric artery replacing the common hepatic artery.

BACKGROUND: Endovascular therapy (ET) for chronic mesenteric ischemia (CMI) is a effective treatment to relieve the symptoms, such as postprandial abdominal pain, food fear, and progressive weight loss. CMI is not known to be caused by rare anatomical variation of severe stenosis of the superior mesenteric artery (SMA), with replaced the common hepatic artery to the SMA. The treatment of such a rare anatomical variation using ET technique has not been discribed. ET with kissing stent technique can be applied to the CMI accompanied with a rare anatomical variation. CASE PRESENTATION: An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15-30 min after every meal. Abdominal computed tomography (CT) showed severe calcification of the SMA origin and bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum. As the patient did not have peritonitis, a conservative approach was used. Angiography performed after symptom resolution showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery. ET with the kissing stent technique, namely stenting to the SMA and common hepatic artery, was successfully performed and relieved the patient's symptoms. CONCLUSIONS: CMI cause the symptoms of Pneumatosis intestinalis (PI) and pneumoperitoneum. Severe stenosis of the SMA origin replacing the common hepatic artery is a rare anatomic variation, which can cause CMI symptoms. ET with a kissing stent is the effective treatment option for the mesenteric artery stenosis accompanied with such rare anatomical variation.

Clinical significance of a false lumen pathway through the arch in acute type A aortic dissection and its influence on cervical branch compromise.

OBJECTIVES: Upon onset of acute type A aortic dissection, the aortic true lumen generally becomes fixed around the supra-aortic branches in the greater curvature and Botallo's ligament in the lesser curvature of the aortic arch. Therefore, the pathways of the false lumen through the arch can be categorized as anterior, bilateral and posterior. We investigated the relationship between a false lumen pathway through the arch and cervical branch compromise, stratified by primary tear location. METHODS: Sixty-four consecutive patients with acute type A aortic dissection underwent emergency surgery at our institution between March 2005 and October 2013. Of these, 40 cases (63%) were DeBakey type I, 15 cases (23%) were type II and 9 cases (14%) were type III-D (retrograde type A). We conducted a retrospective review of preoperative computed tomographic angiography using three-dimensional image post-processing tools for 43 cases, excluding 15 cases with type II and 6 cases with type I for which preoperative digital image data were not available. RESULTS: Of the 43 cases, 14, 18 and 11 revealed anterior, bilateral and posterior pathways, respectively. Twenty-one cases (49%) showed a primary intimal tear in the ascending aorta (8 anterior, 12 bilateral and 1 posterior), 12 cases (28%) showed a primary intimal tear in the aortic arch (5 anterior, 3 bilateral and 4 posterior) and 10 cases (23%) showed a primary intimal tear in the descending aorta (1 anterior, 3 bilateral and 6 posterior). Twelve of the 14 anterior pathway cases (86%) had a total of 26 supra-aortic branch compromises, 13 of the 18 bilateral pathway cases (72%) had a total of 20 supra-aortic branch compromises, while only 4 of the 11 posterior pathway cases (36%) had a total of four supra-aortic branch compromises. None of the 11 posterior pathway cases had a dissection extending into all 3 supra-aortic branches. CONCLUSIONS: Posterior pathway cases generally showed primary tear locations in the arch or descending aorta, and cervical branch compromise was rare. Aortic dissections tended to extend into the cervical branches through the anterior side of the aortic arch. A false lumen pathway through the arch was strongly associated with cervical branch compromise in acute type A aortic dissections.

A new classification system for branch artery perfusion patterns in acute aortic dissection for examining the effects of central aortic repair.

OBJECTIVES: We developed a new classification system for branch perfusion patterns in acute aortic dissection and used it to retrospectively evaluate the perfusion status of whole aortic branches and to examine the effects of central aortic repair. METHODS: Thirty-four consecutive patients with acute type A aortic dissection underwent emergent surgery at our institution between August 2008 and December 2011. A retrospective review of pre- and postoperative computed tomographic angiography was performed. Branch perfusion patterns were categorized into three classes: Class I, dissection involving but not extending into the branch; Class II, dissection extending into the branch and Class III, dissection causing ostial avulsion. RESULTS: In cervical branches (total 169 branches), 70 branches (41%) presented with Class I patterns, 58 (34%) with Class II and none with Class III. In abdominal branches (total 135 branches), 76 branches (56%) presented with Class I patterns, 12 (9%) with Class II and 18 (13%) with Class III. In common iliac arteries (total 68 arteries), 14 arteries (21%) presented with Class I patterns, 24 (35%) with Class II and none with Class III. After repair, among 21 high-risk cervical branches, 14 branches (67%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch false lumen and 4 (19%) showed no improvement in high-risk perfusion pattern or worsened. Among 22 high-risk abdominal branches, 18 branches (82%) showed improvement, 3 (14%) preserved distal perfusion supplied through the patent branch or aortic false lumen and 1 (5%) showed no improvement in high-risk perfusion pattern. CONCLUSIONS: To overcome malperfusion syndromes associated with acute aortic dissection, recognition of diverse branch perfusion patterns through a universal classification system is imperative.

Left ventricular perforation and dissecting subepicardial hematoma after catheter ablation for Wolff-Parkinson-White syndrome.

Radiofrequency catheter ablation of accessory bypass tracts has become a widely accepted therapy for Wolff-Parkinson-White (WPW) syndrome. The procedure typically has a high success rate with a low incidence of complications. Left ventricular perforation is a rare but serious complication of catheter ablation. Here we describe a patient who developed left ventricular perforation and a dissecting subepicardial hematoma with cardiac tamponade following catheter ablation for WPW syndrome. Immediate hematoma evacuation and direct repair of the fragile myocardium were performed under cardiopulmonary bypass, and the patient survived with no further complications.

A resected case of solitary pancreatic metastasis from adenocarcinoma of the lung.

CONTEXT: Primary lung cancer frequently metastasizes to distant organs; however, the pancreas is a relatively infrequent site of metastasis. Because most metastatic cases in the pancreas tend to be discovered in patients only after malignant disease has become widely disseminated, it is extremely rare that a metachronous metastatic lesion limited to the pancreas is discovered with postoperative imaging and is surgically resectable. Most patients demonstrate accompanying metastases to other organs, especially in cases of lung cancer, which prove to be surgically unresectable when diagnosed. Although several cases have been reported of patients who underwent pancreatic resection for curative intent, most patients died from recurrent disease. CASE REPORT: We report herein an unusual case of secondary tumor of the pancreas (primary tumor: adenocarcinoma of the lung) with hopefully curative resection. The interval between the surgical treatment of lung cancer and the metachronous pancreatic metastasis was 22 months; there has been no recurrence of disease during the 24 months of follow-up after a pylorus-preserving pancreaticoduodenectomy. CONCLUSION: Surgical treatment should be considered in patients with pancreatic metastasis from other organs if the disease is localized in the pancreas or if metastasis in other organs is controlled with chemotherapy and/or radiotherapy.

[Surgical experience of 6 multiple primary lung cancers].

Recently, we often meet multiple primary lung cancers with ground glass opacity (GGO). It is necessary for us to find suitable strategy to each case. We report a rare case with 6 lesions all of which were resected surgically. A 60-year old male visited our hospital for examination of abnormal shadows on the chest X-ray. Computed tomography (CT) scan showed 5 GGO lesions in the lung field (2 in the left lower lobe, 2 in the right upper lobe, 1 in the right middle lobe). He underwent left S6 segmentectomy as a 1st surgery, followed by wedge resection of the right upper lobe with right middle as a 2nd surgery. Pathologically, they were type A and B of the Noguchi classification. After 3-year follow-up, a new lesion developed in the right lower lobe and was resected by right lower lobectomy. It was invasive papillary adenocarcinoma. As a consequence, 6 lesions were all removed safely. The patient has been well without recurrence for 1 year after the last surgery.

Barium-enhanced imaging of the coronary vasculature of the porcine myocardium: empirical investigation into the theory of the ventricular myocardial band.

OBJECTIVE: The ventricular myocardium is thought to exist as a single continuous muscle band that extends from the pulmonary artery to the aorta, wrapped into a double helical coil Torrent-Guasp's theory of the ventricular myocardial band (VMB). The purpose of this study was to examine the coronary blood supply to the VMB and to evaluate the effect of coronary blood systems on structure-function relations in the myocardium. METHODS: VMBs of nine swine hearts were unwrapped after postmortem barium coronary angiography. Unwrapped VMBs underwent radiography, and vascular images of barium remaining in the VMBs were evaluated. RESULTS: We were able to achieve a single longitudinal and stretched myocardial band in all nine porcine hearts. The corresponding regions supplied by each coronary artery were clearly distinguishable in the VMBs. The right segment of the basal loop was supplied by the right coronary artery. The left segment of the basal loop was supplied by the left circumflex artery. Most of the descending segment of the apical loop was supplied by the left anterior descending artery, with an inferior portion supplied by the right coronary artery. Most of the ascending segment of the apical loop was supplied by the left anterior descending artery, with a posterior portion supplied by the left circumflex artery. CONCLUSION: Understanding the trinity of structure, function, and coronary blood supply from the viewpoint of the VMB should facilitate development of more effective surgical treatment for severe ischemic heart disease.