Diaphragmatic repair of two cases of hepatic hydrothorax using video-assisted thoracoscopic surgery.

Hepatic hydrothorax is defined as the presence of a significant pleural effusion that develops in a patient with cirrhosis of the liver who does not have underlying cardiac or pulmonary disease. There are few published case reports dealing with hepatic hydrothorax treated surgically because patients with hepatic hydrothorax have end-stage liver disease. Recently, we treated two patients with refractory hepatic hydrothorax by directly suturing the diaphragmatic defects during video-assisted thoracoscopic surgery (VATS). During surgery, the diaphragmatic defects were identified using abdominal insufflation of saline with indocyanine green or carbon dioxide. After suture closure using fibrin glue, both right pleural effusions were improved. The patients' postoperative courses were uneventful, and they did not require a drainage tube when they were discharged.

Hereditary factors in multiple primary malignancies associated with lung cancer.

PURPOSE: There are differences between lung cancer alone and multiple primary malignancies associated with lung cancer (MPMLC) in terms of clinical characteristics. However, the importance of these differences has not yet been clarified. METHODS: Univariate and multivariate analyses were performed on 123 patients with MPMLC and 815 patients with lung cancer alone who underwent operative procedures for lung cancer from August 1982 to March 2004. RESULTS: Age, number of family with a family history of other malignancies except for smoking-related cancers, and pathological early stage of lung cancer were significantly high in patients with MPMLC based on univariate analyses (P < 0.0001, P < 0.05, and P < 0.05, respectively). Age and family history of malignancy were thus found to be significant factors based on a multivariate analysis. CONCLUSIONS: MPMLC demonstrated a significant association with advanced age and stronger hereditary factors in comparison with lung cancer alone, indicating the need for different approaches to properly manage and follow up risk patients.

Characteristics of multiple primary malignancies associated with lung cancer by gender.

BACKGROUND: There are gender differences in multiple primary malignancies associated with lung cancer (MPMLC) in terms of clinical characteristics. However, the importance of these differences in the management of patients has not been clarified. OBJECTIVE: Differences in characteristics affected by gender were investigated in MPMLC to identify factors important for the proper management of the patients. METHODS: Univariate and multivariate analyses were performed between 82 male and 34 female patients with MPMLC treated from August 1982 to March 2002. RESULTS: In univariate analysis, the numbers of smokers or ex-smokers, smoking-related cancer and synchronous multiple primary malignancies were significantly increased in males with MPMLC (p < 0.0001, p < 0.05 and p < 0.05, respectively). In multivariate analysis, synchronous multiple primary malignancies and the number of smokers or ex-smokers were significantly different between male and female MPMLC. Gastric, lung and colon cancers were major constituents in male MPMLC, and 40.2% of all malignancies were smoking-related cancers. On the other hand, breast and uterine cancers were major constituents in female MPMLC, and only 20.6% of all MPMLC were smoking-related cancers. CONCLUSIONS: Male patients with MPMLC demonstrated significant smoking history and synchronous multiple primary malignancies, indicating the need for different approaches to properly manage and follow up male versus female MPMLC patients.

Enucleation of esophageal leiomyoma with azygos continuation of the inferior vena cava: report of a case.

We herein report a rare case of esophageal leiomyoma in an 18-year-old woman with azygos continuation of the inferior vena cava. A submucosal tumor was located in the left wall of the esophagus behind the carina. The enlarged azygos vein made video-assisted thoracic surgery so difficult that conversion to a minithoracotomy and transection of the right superior intercostal vein were necessary to fully visualize the tumor. A pathological diagnosis revealed leiomyoma. Our experience suggests that a transection of the right superior intercostal vein is effective for the proper exposure of an esophageal tumor located behind the carina in a patient with an enlarged azygos vein.

Resection of sternal tumors and reconstruction of the thorax: a review of 15 patients.

PURPOSE: We report our experience of resecting sternal tumors, followed by reconstruction of the skeletal and soft-tissue defects, and discuss the usefulness of sandwiched Marlex and stainless-steel mesh. METHODS: Fifteen patients underwent resection of a sternal tumor and chest wall reconstruction with autologous bone grafts, sandwiched Marlex and stainless-steel mesh or a titanium plate, and musculocutaneous flaps. The sternal tumors were from locally recurrent breast carcinoma in ten patients, metastasis from other organs in three, and primary chondrosarcoma in two. RESULTS: All patients were extubated without paradoxical respiration just after surgery. There was no operative mortality. A wound infection developed in the acute phase after a sandwiched Marlex and stainless-steel mesh reconstruction in one patient. A second repair with Marlex and stainless-steel mesh was required in two patients; for flail chest after an autologous bone graft in one; and following re-recurrence of breast carcinoma in another patient who had undergone a musculocutaneous flap repair. No signs of breakdown, dislodgment, severe depression, or deformity were seen in any of the six patients who underwent reconstruction with Marlex and stainless-steel mesh during a median follow-up period of 56 months. CONCLUSIONS: Wide resection of sternal tumors provides good local control. Reconstruction with Marlex and stainless-steel mesh seems to be the most effective technique for repairing a wide anterior chest wall defect.

Resection of sternal metastasis from endometrial carcinoma followed by reconstruction with sandwiched marlex and stainless steel mesh: report of a case.

We report the successful resection of sternal metastasis from endometrial carcinoma, followed by reconstruction of the chest defect, in an 87-year-old woman. We performed subtotal sternectomy and concurrent resection of the ribs and overlying soft tissue. The skeletal defect was then reconstructed with sandwiched Marlex and stainless steel mesh, and soft tissue coverage was accomplished by using a pectoralis major advancement flap. The patient had an uneventful postoperative course with no sign of recurrence during 5 years of follow-up. Thus, reconstruction with Marlex and stainless steel mesh could be an effective technique for preventing paradoxical movement of the thorax and protecting the intrathoracic organs.

A case report on a full-thickness chest wall reconstruction with polypropylene mesh and stainless steel mesh concurrently using a transverse rectus abdominis myocutaneous flap.

A full-thickness chest wall resection requires subsequent chest wall reconstruction. A chest wall resection and reconstruction was performed using a transverse rectus abdominis myocutaneous (TRAM) flap, together with polypropylene mesh (Marlex mesh) and stainless steel mesh (SSM). A 71-year-old man was diagnosed as having recurrent lung cancer in the chest wall, and underwent surgical resection. Marlex mesh was sutured to the posterior wall of the surgical defect. A portion of the SSM was adjusted to the size of the defect and cut out. Its edges were folded to make the portion into a plate. This SSM plate was placed anteriorly to the Marlex mesh and sutured to the ribs. The Marlex mesh was folded back on the SSM plate by 2 cm and fixed. After the above procedures, a left-sided TRAM flap was raised through a subcutaneous tunnel up to the defect and sutured to the region. The patient was discharged from hospital 19 days postoperatively. The wound was fine and he had no flail chest or dyspnea, and carcinomatous pain resolved.

Determining the plasma concentration of ketamine that enhances epidural bupivacaine-and-morphine-induced analgesia.

N-methyl-D-aspartate (NMDA) receptor antagonists enhance opioid-induced analgesia. The plasma concentration of ketamine, an NMDA receptor antagonist that enhances epidural morphine-and-bupivacaine-induced analgesia, is not known. We examined 24 patients with lung carcinoma or metastatic lung tumor who underwent video-assisted thoracic surgery in a placebo-controlled, double-blind manner 4 h after emergence from anesthesia. The morphine + ketamine group (n = 8) and morphine + placebo group (n = 8) received 5 mL volume of 2.5 mg morphine and 0.25% bupivacaine and the placebo + ketamine group (n = 8) received 5 mL volume of saline and 0.25% bupivacaine epidurally at the end of skin closure. Four hours after this anesthesia, in the morphine + ketamine and placebo + ketamine groups, ketamine was administered to successively maintain a stable plasma ketamine concentration of 0, 10, 20, 30, 40, and 50 ng/mL by a target-controlled infusion device, and patients assessed the levels of pain at rest, pain on coughing, somnolence (drowsiness), and nausea using a 100-mm visual analog scale (VAS). In the morphine + placebo group, a placebo (saline) was similarly administered instead of ketamine. In the morphine + ketamine group, the VAS scores for pain at rest and pain on coughing significantly decreased on ketamine administration at a plasma concentration of 20 ng/mL or larger compared with the respective baseline VAS scores (P < 0.05 each). In the placebo + ketamine group, the VAS scores for pain at rest and pain on coughing did not significantly change at any plasma concentration of ketamine as compared to the morphine + placebo group. In the morphine + ketamine group, a plasma concentration of ketamine larger than 20 ng/mL did not further reduce VAS scores for pain at rest and pain on coughing. The VAS scores for drowsiness were comparable among the three groups at any plasma concentration of ketamine. Ketamine at a plasma concentration of 20 ng/mL or larger may enhance epidural morphine-and-bupivacaine-induced analgesia. As an adjunct with epidural morphine-and-bupivacaine and considering the safety of small doses, the minimal plasma concentration of ketamine given IV may be approximately 20 ng/mL.

Paraganglioma of the posterior mediastinum diagnosed by immunohistochemical staining.

Paraganglioma of the mediastinum are rare neoplasms. To date, no definitive morphologic criteria exist that correlate with the clinical outcome of these tumors. We have encountered a case of paraganglioma in which biological behavior was assessed by immunohistochemical staining to determine whether supplementary postoperative treatment was needed. A 28-year-old man came to our hospital because of an abnormal shadow on a radiogram of the chest. He had no symptoms. Hematological findings were unremarkable. Diagnostic imaging suggested a neurogenic tumor. Surgical resection was performed in September, 2002. A typical nesting pattern (Zellballen) and positivity for chromogranin on immunohistochemical staining were evident, indicating neuroendocrine characteristics, and paraganglioma was diagnosed. Tissue specimens indicated an MIB-1-labeling index of 1.3% on MIB-1 staining, and a relatively well maintained distribution of S-100 protein-positive sustentacular cells, which were suggestive of a benign tumor. The patient did not receive any supplementary therapy postoperatively but was given careful follow-ups.

Human pulmonary dirofilariasis in a patient whose clinical condition altered during follow-up.

Pulmonary dirofilariasis is a rare disease. We have experienced a case which developed pleural effusion while being followed, rendering it difficult to establish the diagnosis. The patient, a 53-year-old woman, had previously undergone two operations; one for uterine cancer and another for breast cancer. She developed a cough in February 2002, and chest computed tomography (CT) scans disclosed a nodular mass in the right lung. A biopsy revealed a fibrous nodule with macrophage aggregation. Pleural effusion was demonstrated on chest CT scans performed in May. As the possibility of malignant tumor could not be ruled out, an operation was undertaken. The nodular lesion showed marked coagulation necrosis, and dead parasites were noted in the vascular lumen. The parasites had the characteristic morphological features of Dirofilaria immitis. Immunological studies produced a positive test result for the anti-dirofilaria immitis antibody; hence a diagnosis of pulmonary dirofilariasis was made.