Optimal methodology for percutaneous dilatational tracheostomy: a comparative analysis between conventional and multidisciplinary approaches utilizing ultrasound, flexible bronchoscopy, and microcatheter puncture in critically ill individuals of diminutive stature-a longitudinal single-institutional experience and retrospective analysis.

Background: Percutaneous dilatational tracheostomy (PDT), a bedside procedure in intensive care, enhances respiratory support for critically ill patients with benefits over traditional tracheostomy, such as improved safety, ease of use, cost-effectiveness, and operational efficiency by eliminating patient transfers to the operating room. It also minimizes complications including bleeding, infection, and inflammation. Despite decades of PDT evolution and device diversification, adaptations primarily cater to larger Western patients rather than smaller-statured Korean populations. This study assesses the efficacy and appropriateness of the Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IN, USA), augmented with ultrasound, flexible bronchoscopy, and microcatheter techniques, for Korean patients with short stature. Methods: We conducted PDT on 183 intubated adults (128 male/55 female) with severe respiratory issues at a single medical center from January 2010 to December 2022. Patients were divided into two groups for retrospective analysis: a modified group (n=133) underwent PDT with ultrasound-guided flexible bronchoscopy and microcatheter puncture, and a conventional group (n=50) received PDT using only the Ciaglia Blue Rhino device. We assessed clinical and demographic characteristics, outcomes, and complications such as pneumothorax and emphysema. The study also evaluated the suitability and effectiveness of the devices for Korean patients with short stature. Results: Demographic characteristics including sex, body weight, height, body mass index, obesity status, and underlying diseases showed no significant differences between the two groups. However, the modified group was older (69.5±14.2 vs. 63.5±14.1 years; P=0.01). The sequential organ failure assessment (SOFA) and simplified acute physiology score (SAPS) II score was slightly higher in the modified groups, but no statistically significant differences were observed (7.1±2.3 vs. 6.7±2.3, P=0.31 and 46.7±9.0 vs. 44.0±9.1, P=0.08, respectively). The duration of hospital and ICU stays, as well as days post-PDT, were longer in the conventional group, yet these differences were not statistically significant (P=0.20, P=0.44, P=0.06). Total surgical time, including preparation, ultrasound, bronchoscopy, and microcatheter puncture, was significantly longer in the modified group (25.6±7.5 vs. 19.9±6.5 minutes; P<0.001), and the success rate of the first tracheal puncture was also higher (100.0% vs. 92.0%; P=0.006). Intra-operative bleeding was less frequent in the modified group (P=0.02 for tracheostomy site bleeding and P=0.002 for minor bleeding). Conclusions: PDT, performed at the bedside in intensive care settings, proves to be a swift and dependable method. Utilizing the Ciaglia Blue Rhino device, combined with ultrasound guidance, flexible bronchoscopy, and 4.0-Fr microcatheter puncture, PDT is especially effective for intubated patients who cannot be weaned from ventilation. This technique results in fewer complications than traditional tracheostomy and is particularly beneficial for patients with respiratory issues and smaller-statured Koreans, potentially reducing morbidity and mortality.

Clinical application of a digital thoracic drainage system for objectifying and quantifying air leak versus the traditional vacuum system: a retrospective observational study.

BACKGROUND: Digital thoracic drainage systems have recently been introduced and widely used in clinical practices in developed countries. These systems can monitor intrathoracic pressure changes and air leaks in real time, and also allow for objective and quantitative analyses, which aid in managing patients with a prolonged persistent air leak into the pleural space. We investigated the feasibility and effectiveness of such a new device versus the traditional vacuum system for treating patients with pneumothorax. METHODS: Closed thoracostomy drainage was carried out on 100 adult patients with primary or secondary pneumothorax between January 2017 and December 2018. All the patients were aged ≥18 years and treated with a chest tube at a single medical center by the same cardiothoracic surgeons and intensivists. Patients who underwent closed thoracostomy drainage using an indwelling 24-French chest tube were divided into 2 groups immediately before closed thoracostomy: the digital thoracic drainage group (digital group, n=50) and the traditional analogue thoracic drainage group (analogue group, n=50). The detailed information about demographic data, treatment outcome, duration of indwelling catheterization., hospital days, cost-effectiveness and patient satisfaction was evaluated. We also evaluated whether digitally recorded intrapleural pressure changes and air leaks would predict chest tube removal timing and outcome. RESULTS: The baseline parameters of the 2 groups were comparable with no significant differences in sex, age, weight or body mass index. The mean hospital day was shorter in the digital group than in the analogue group (17.96±12.23 vs. 18.32±16.64, P=0.902), and there was no statistically significant difference in the hospital length of stay between the 2 groups. Air leaks through the chest tube and duration of chest tube indwelling hours showed no significant statistical differences between the digital and analogue groups (213.47±219.80 vs. 261.94±184.47, P=0.235 and 223.44±218.75 vs 275.29±186.06, P=0.205, respectively). Total drainage amount and ambulation time per day were significantly higher in the digital group than in the analogue group [209.62±139.63 vs. 162.48±80.42 (P=0.042) and 6.42±3.62 vs.3.94±1.74 (P<0.001), respectively]. Hours of full expansion were significantly shorter and sleep disturbance caused by the noise of chest tube drainage was less in the digital group than in the analogue group [25.64±14.55 vs. 46.52±25.53 (P<0.001) and 2.38±1.03 vs. 5.70±2.87 (P<0.001), respectively]. CONCLUSIONS: To date, there is no definite consensus and guidelines on the standardized digital suction system in pneumothorax. This study proposed the guidelines for the application of digital thoracic drainage systems in pneumothorax and also suggested that digital thoracic drainage systems might be a valuable tool to determine chest tube removal timing and reducing the length of hospital stay in patients with pneumothorax.

Femoral arteriovenous fistula associated with surgery of proximal femoral fracture: a systematic review of the literature and case presentation.

BACKGROUND: Proximal femoral fracture (PFF), such as intertrochanteric femoral fracture or femur neck fracture, and its management are crucial issues to surgeons. PFF has been dramatically is becoming exponentially prevalent, and it is at high risk of complication and mortality because it is frequently associated with serious trauma and advanced age, especially in patients treated with anticoagulants or antiplatelet agents. Surgical management is essential for the treatment of PFF. Unfortunately, current surgical procedures have been related to accompanied by vascular complications, including laceration, hemorrhage, thrombosis, embolism, intimal flap tear and pseudoaneurysm. Furthermore, these vascular injuries following surgical management of PFF are potentially limb- and life-threatening. Of the complications after operation of PFF, femoral arteriovenous fistula (AVF) is rare, but remains a challenging problem because it is frequently associated with significantly high mortality and morbidity and is very difficult to treat. METHODS: A systematic literature review was conducted using the PRISMA guidelines with no language restriction. We searched scientific publications via PubMed, Embase, Cochrane central register of controlled trial, Google Scholar, the KoreaMed and the Research Information Sharing Service database. The goal of this study was to report on the incidence, clinical presentation, diagnosis, treatment, associated complications, morbidity and mortality of femoral AVF caused by PFF and to draw special attention to its prevention and management. RESULTS: A total of 7 case reports on femoral AVF associated with operation of PFF were identified, and one our case was added to the systematic analysis. Of the 8 cases, 4 were male and 4 were female under the age of 67.87±18.44; 6 (75.0%) survived without any events, 1 (12.5%) survived with a sequela of peroneal nerve impairment, and 1 (12.5%) died of multi-organ failure and hypovolemia. CONCLUSIONS: The incidence of femoral AVF associated with PFF is extremely low, though it appears to increase with the rising frequency of PFF. With a very few exceptions, complications following internal fixation are potentially limb- and life-threatening. There is still no definite consensus on the standardized diagnostic or therapeutic modalities. Therefore, surgeons should keep in mind that this serious complication requires early diagnosis and prompt treatment, which should not be underestimated. Femoral AVF following operation of PFF should be meticulously managed, because untreated fistulae result in serious unexpected complications including renin-mediated hypertension, high-output heart failure and venous and/or arterial insufficiency. Surgical treatment is still the gold standard for such cases, but in limited cases endovascular procedures using embolization and closure device can be a good treatment option.

Computed tomography-guided percutaneous hook wire localization of pulmonary nodular lesions before video-assisted thoracoscopic surgery: Highlighting technical aspects.

OBJECTIVE: Confirming the histologic diagnosis of small pulmonary nodules or Ground-glass opacity nodules (GGNs) of unknown origin is difficult. These nodules are not always appropriate for percutaneous transthoracic needle biopsy. Preoperative localization of pulmonary lesions provides more precise target points to ensure complete surgical excision. The goal of the present study was to evaluate the validity and effectiveness of computed tomography-guided preoperative hook wire localization with our technique for video-assisted thoracoscopic surgery (VATS). METHODS: We retrospectively investigated 113 patients who had undergone preoperative hook wire localization before VATS resection for newly present or growing pulmonary nodular lesions between May 2007 and December 2016. Procedural and perioperative outcomes were assessed to evaluate the safety and efficacy of preoperative localization technique. RESULTS: A total of 113 pulmonary nodules were localized and successfully resected in all 113 patients. The mean diameter of nodules was 10.8 ± 6.1 mm (range, 3-28). The mean distance from the pleural surface was 20.2 ± 12.4 mm (range, 5-55). The mean procedure time of localization was 23.7 ± 6.3 min. Asymptomatic minimal pneumothorax and mild parenchymal hemorrhage occurred in 26 (23.0%) and 8 (7.1%) patients, respectively. There were 32 (28.3%) deep lung nodules, in which the distance to pleural surface was more than 25 mm. Wire dislodgement occurred in 4 (3.5%) patients. Complete resection of all lung lesions was achieved, and definite histological diagnosis was obtained in all patients. Pathologic examination revealed 42 (37.2%) primary lung cancers, 2 (1.8%) lymphomas, 53 (46.9%) metastases, 16 (14.1%) benign lesions. CONCLUSIONS: Preoperative percutaneous hook wire localization is a dependable and useful technique to facilitate positioning small and deep pulmonary nodules for thoracoscopic complete excision and accurate diagnosis.

Effects of glycyrrhizin on lipopolysaccharide-induced acute lung injury in a mouse model.

BACKGROUND: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are serious clinical disease entities characterized by inflammatory pulmonary edema, which lead to acute hypoxic respiratory failure through various etiologies. According to the studies to date, ALI/ARDS has been recognized as a form of multiorgan failure related to overactive immune response, and overproduction of proinflammatory cytokines released from activated inflammatory cells are considered to play a key role in the development of ALI. Glycyrrhizin (GL) is an extractive component derived from Glycyrrhiza glabra (licorice), which has recently been reported to have various pharmacological effects like anti-inflammatory, anti-tumor, hepato-protective, and anti-viral activities. Nevertheless, the therapeutic effect of GL in ALI is still unclear. The aim of this study was to investigate therapeutic effects of GL on lipopolysaccharide (LPS)-induced ALI in a mouse model and to elucidate explicable mechanisms involved. METHODS: A total of 36 BALB/c mice (6-week-old, 27.7±1.9-gram body weight) were randomly divided into 3 groups: the control group (normal saline was administered intravenously, n=10), the LPS group (LPS 50 mg/kg was intraperitoneally administered, n=13), and the LPS + GL group (GL was administered intravenously immediately and 12 hours after LPS injection, n=13). Mice were sacrificed after 24 hours, and bronchoalveolar lavage fluid (BALF) was collected for the estimation of protein content, inflammatory cell counts, proinflammatory cytokines, myeloperoxidase (MPO) activity, and expressions of cyclooxygenase-2 (COX-2), inducible nitric oxide synthase (iNOS), and nuclear factor kappa B (NF-κB). Then, the lungs were excised for molecular target, histopathological, and immunohistochemical examinations. RESULTS: Compared to the LPS group, GL significantly decreased protein content, inflammatory cell counts, tumor necrosis factor-α (TNF-α), interleukin-1α (IL-1α), IL-6, MPO activity, and expressions of COX-2, iNOS, and NF-κB in the LPS + GL group. GL attenuated migration and infiltration of inflammatory cells, showing a marked decrease in CD 11b-positive cells (26.77%±0.83% vs. 41.77%±0.81% vs. 23.23%±1.92%, P<0.05) as well as CXCR4-/CXCR1-positive cells (CXCR4: 37.23%±1.00% vs. 59.37%±2.37% vs. 47.45%±4.36%; CXCR1: 32.10%±1.56% vs. 47.03%±1.99% vs. 21.70%±6.50%; all P<0.05) in the control, LPS, and LPS + GL groups. Additionally, immunohistochemistry showed that the expression of Toll-like receptor 4 (TLR-4) was inhibited by GL. CONCLUSIONS: The results of this study indicate that GL may have anti-inflammatory and protective effects on LPS-induced ALI in mice. GL inhibited proinflammatory cytokines playing a key role in the initial phase of inflammatory response, which suggests that inhibition of the TLR-4/NF-κB signal pathway would be a possible mechanism underlying the action of GL. Thus, GL can be used as a novel therapeutic strategy for pulmonary inflammation.

Spontaneous lumbar artery rupture and massive retroperitoneal hematoma, successfully treated with arteriographic embolization.

BACKGROUND AND OBJECTIVE: Massive retroperitoneal hematoma caused by lumbar artery rupture is generally associated with trauma or retroperitoneal malignancy. However, despite recent advances in technologies and tools, spontaneous lumbar artery rupture is a very rare disease entity but remains a challenging problem because it is frequently associated with significantly high mortality and morbidity and is very difficult to make a correct diagnosis. METHODS: We evaluated the databases of the PubMed, Embase, Cochrane Central Register of Controlled Trial, Google Scholar, the KoreaMed and the Research Information Sharing Service databases, and a detailed systematic review was performed by searching in PubMed. The initial search was performed on 3 February 2018 and a second search conducted in 29 January 2019. RESULTS: A total of 10 case reports on massive hemoperitoneum caused by spontaneous lumbar artery rupture were identified. Of the 10 case reports involving 14 patients, eight were male and six were female under 62.71 ± 13.93. Of the 14 patients, 9 (64.3%) surviving with transcatheter arterial embolization, three (21.4%) died of multi-organ failure or hypovolemia, and two (14.3%) had no definite records on survival or death. CONCLUSIONS: A massive retroperitoneal hematoma caused by lumbar artery rupture should be considered in patients with late-onset shock accompanied by blunt abdominal/pelvic trauma. Furthermore, early detection and urgent embolization would prevent further complications and eliminate the need for surgical interventions.

Clinical implications of the initial SAPS II in veno-arterial extracorporeal oxygenation.

BACKGROUND: Prediction of survival and weaning probability in VA ECMO (veno-arterial extracorporeal membrane oxygenation) patients could be of great benefit for real-time decision making on VA ECMO initiation in critical ill patients. We investigated whether the SAPS II score would be a real-time determinant for VA ECMO initiation and could be a predictor of survival and weaning probability in patients on VA ECMO. METHODS: Between January 1, 2010 and December 31, 2014, VA ECMO was carried out on 135 adult patients suffering from primary cardiogenic shock. To avoid selection bias, we excluded respiratory failure patients treated with VV or other types of ECMO. Successful VA ECMO weaning was defined as weaning, followed by stable survival for more than 48 hours. Survival after VA ECMO was defined as successful weaning and treatment of the underlying medical condition, followed by discharge without any further events. RESULTS: A total of 135 patients consisted of 41 women and 94 men, with a mean age of 59.4±16.5 years. Fifty-three patients had successful weaning, and 35 survived and were discharged uneventfully. Compared to the non-survivors, the survivors showed a lower SAPS II (67.77±20.79 vs. 90.29±13.31, P<0.001), a lower SOFA score (12.63±3.49 vs. 15.33±2.28, P<0.001), a lower predicted death rate (71.12±30.51 vs. 94.00±9.36, P<0.001), a higher initial ipH (7.14±0.22 vs. 6.98±0.15, P<0.001), and a lower initial lactate level (7.09±4.93 vs. 12.11±4.84, P<0.001). The average duration of hospital stay in the successful vs. failed weaning groups was 33.43±27.41 vs. 6.35±8.71 days, and the average duration of ICU stay in the successful vs. failed weaning groups was 20.60±16.88 vs. 5.39±5.95 days. By multivariate logistic regression analysis of initial parameters for VA ECMO assistance, the simplified acute physiology score II (SAPS II) (OR =1.1019, P=0.0389), ipH (OR =0.0010, P=0.0452), and hospital stay (OR =0.8140, P=0.001) had an association with in-hospital mortality on VA ECMO. The initial SAPS II score [area under the curve (AUC) =0.821] demonstrated significantly superior prediction of VA ECMO mortality than age (AUC =0.697), SOFA score (AUC =0.701), ipH (AUC =0.551), and the other parameters. By multivariable CoX regression analysis of survival, only the SAPS II score proved to have statistical significance (hazard ratio, 1.0423; 95% CI, 1.0083-1.0775; P=0.01). CONCLUSIONS: Although the precise predictive scoring systems for VA ECMO still remains one of the most difficult challenges to ECMO physicians, the SAPS II score could provide valuable information on prognosis to patient himself, family members and caretakers, and might help physicians increase the survival rate and might avoid a waste of healthcare resources.

Postoperative chest tube placement after thoracoscopic wedge resection of lung for primary spontaneous pneumothorax: is it mandatory?

BACKGROUND: The goal of present study is to assess the efficiency and feasibility of postoperative care without positioning of chest tube after video-assisted thoracoscopic surgery (VATS) in patients with primary spontaneous pneumothorax (PSP). METHODS: We conducted a prospective randomized trial of patients who have undergone video-assisted thoracoscopic wedge resection surgery for PSP. During the period of April 2015 until December 2016, 119 eligible patients undergoing VATS for PSP were consecutively included. We divided the patients into two groups at random: (I) avoiding chest tube (ACT) group, comprising 58 patients in whom chest tube was not placed intra or postoperatively, and (II) indwelling chest tube (ICT) group, comprising 61 patients in whom chest tube was placed conventionally. Primary end point was to evaluate and analyze the postoperative clinical data and relevant morbidities between two groups. RESULTS: The mean postoperative length of hospital stay (3.57±0.79 vs. 5.39±0.97 days) and postoperative pain (1.37±0.78 vs. 2.53±0.63) in ACT group were significantly lower than in the ICT group (P<0.05). However, there were no statistical differences between two groups regarding other clinical data and postoperative morbidities. There were no patients who experienced significant adverse events postoperatively. CONCLUSIONS: Postoperative management without chest tube placement is safe and feasible approach for patients undergoing thoracoscopic wedge resection for PSP.

The management of chemical pleurodesis with viscum album in patients with persistent air leakage.

BACKGROUND: Persistent air leak (PAL) after major pulmonary resection or involved with secondary lung disease is prevalent and associated with significant morbidity. Chemical pleurodesis is a practical therapeutic tool to manage the patients with PAL. Among various sclerosing substances, viscum album (fraxini) is considered effective and safe. The aim of this study was to evaluate the efficacy and safety of viscum album pleurodesis in patients with intractable prolonged air leakage. METHODS: Between February 2013 and February 2015, 73 consecutive patients who underwent pleurodesis due to PAL were enrolled in this study. Pleurodesis was performed using 100 mg of viscum album (fraxini) at 1 time through the indwelling chest tube. Main studied outcomes were focused on success rate of pleurodesis assessed on chest radiography and cessation of the air leak after procedure. RESULTS: The study population was predominantly male (n=64, 87.7%). The overall success rate was 90.4%. One patient died of pneumonia not related to the viscum album pleurodesis. The mean length of stoppage to air leakage was 28.00±22.19 hours. The mean duration of chest tube drainage after pleurodesis was 2.78±1.35 days. The mean number of pleurodesis was 1.38±0.75. Thirty-six patients (49.3%) complained of chest pain requiring a prescription for pain control. There were no major relevant complications or mortalities. CONCLUSIONS: Air leaks remain an important cause of morbidity. This viscum album pleurodesis could be considered as an option for the treatment of prolonged air leak patients, associated with acceptable side effects.

Extramedullary Hematopoiesis Mimicking Mediastinal Tumor in a Patient with Hereditary Spherocytosis: Case report.

INTRODUCTION: Extramedullary hematopoiesis (EMH) is a rare disorder, defined as the appearance of hematopoietic elements outside the bone marrow or peripheral blood. The exact mechanism of this development is still unknown. We herein report a case of intrathoracic EMH, manifesting as a posterior mediastinal tumor in a patient with hereditary spherocytosis. PRESENTATION OF CASE: A 45-year-old man who presented with anemia, jaundice and abdominal pain was diagnosed with hereditary spherocytosis. A 2.6cm homogeneous right paravertebral (at the level of T8) round mass of soft tissue density was discovered incidentally on computed tomography. We performed a complete excision of mass lesion by video-assisted thoracoscopic surgery (VATS) to confirm the diagnosis. It appeared to be well encapsulated and contained bloody, fragile material. A pathological result disclosed a normal diffuse hematopoiesis consisting of megakaryocytes, immature granulocytic and myeloid precursor cells, and finally confirmed a diagnosis of EMH. Furthermore, laparoscopic splenectomy and cholecystectomy surgery was accomplished uneventfully as well. DISCUSSION: It was very significant to differentiate posterior mediastinal neurogenic tumor from EMH, as it can be clinically confused with other tumors of the mediastinum. Radiological examination has limitations, so definite diagnostic confirmation by surgical approach should be considered. CONCLUSION: We successfully performed a complete removal of intrathoracic mediastinal mass and confirmed a diagnosis of extramedullary hematopoiesis (EMH) which is mimicking mediastinal neoplasm.

Spontaneous Pulmonary Hematoma with No Underlying Causes: A Case Report.

A 57-year-old male patient was admitted to our center because of a cystic mass on the lower portion of the right major fissure that was found incidentally by chest X-ray. He did not have a history of trauma or anticoagulant use. The lesion was removed by video-assisted thoracoscopic surgery. Pathological examination revealed an organizing pulmonary hematoma without any complications, and a follow-up chest X-ray after 1 year showed no recurrence.

Novel Early Predictor of Acute Kidney Injury after Open Heart Surgery under Cadiopulmonary Bypass Using Plasma Neutrophil Gelatinase-Associated Lipocalin.

BACKGROUND: Open heart surgery using cardiopulmonary bypass (CPB) is considered one of the most frequent surgical procedures in which acute kidney injury (AKI) is a frequent and serious complication. The aim of the present study was to evaluate the efficiency of neutrophil gelatinase-associated lipocalin (NGAL) as an early AKI biomarker after CPB in cardiac surgery (CS). METHODS: Thirty-seven adult patients undergoing CS with CPB were included in this retrospective study. They had normal preoperative renal function, as assessed by the creatinine (Cr) level, NGAL level, and estimated glomerular filtration rate. Serial evaluation of serum NGAL and Cr levels was performed before, immediately after, and 24 hours after the operation. Patients were divided into two groups: those who showed normal immediate postoperative serum NGAL levels (group A, n=30) and those who showed elevated immediate postoperative serum NGAL levels (group B, n=7). Statistical analysis was performed using Statistical Package for the Social Sciences version 18. RESULTS: Of the 37 patients, 6 (6/37, 16.2%) were diagnosed with AKI. One patient belonged to group A (1/30, 3.3%), and 5 patients belonged to group B (5/7, 71.4%). Two patients in group B (2/7, 28.5%) required further renal replacement therapy. Death occurred in only 1 patient (1/37, 2.7%), who belonged to group B. CONCLUSION: The results of this study suggest that postoperative plasma NGAL levels can be used as an early biomarker for the detection of AKI following CS using CPB. Further studies with a larger sample size are needed to confirm our results.

A 7.3×5.3×3.5-cm heterotopic thyroid in the posterior mediastinum in a patient with situs inversus totalis.

Ectopic posterior mediastinal thyroid is a very rare clinical disease entity. It accounts for less than 1% of all mediastinal tumors. The mass is difficult to diagnose due to its rarity and non-specific clinical symptoms and thus remains asymptomatic for many years until it becomes larger. Since the mass is considerably large at presentation, it should be distinguished from metastatic thyroid carcinoma. We present herein the case of a 62-year-old woman with situs inversus totalis who complained of atypical chest pain and dysphagia and had a huge posterior mediastinal ectopic thyroid. The patient underwent complete resection through thoracotomy, with relief of symptoms. In summary, although ectopic posterior mediastinal thyroid is a rare disease entity, it should be considered in the differential diagnosis of posterior mediastinal tumors. Surgery is the treatment of choice for posterior ectopic posterior thyroid and its prognosis is excellent following complete resection.

Flail chest stabilization with Nuss operation in presence of multiple myeloma.

Nowadays the Nuss operation has been widely adopted as a minimally invasive procedure and standard surgical choice in pectus excavatum. However, much debate and concern have been raised regarding its applicability in adults with pectus excavatum flail chest and other thoratic wall deformities, as compared with younger patients, in terms of complications after surgery. To stabilize the segment of paradoxical chest wall movement we performed the Nuss operation on a patient with multiple myeloma who sustained blunt thoracic trauma. The patient presented with paradoxical movement of the thoracic wall and sternum instability due to multiple myeloma, which led to severe dyspnea, hypoxemia, hypercapnea, and bedridden state. His condition progressed to acute respiratory distress syndrome and did not respond to conservative treatment. We performed the Nuss operation on the patient, and his clinical symptoms were relieved after surgery. The patient regained the ability to walk unassisted and was discharged from the hospital without any specific events.

Solitary plasmacytoma of the sternum.

Plasmacytoma is a plasma cell neoplasm that locally infiltrates a bone or spreads to extramedullary areas. A new World Health Organization criterion defines solitary plasmacytoma of bone as a localized bone tumor consisting of plasma cells identical to those seen in plasma cell myeloma, which is manifested as a solitary osteolytic lesion in a radiological evaluation. Primary tumors of the sternum are generally malignant, and solitary plasmacytomas of the sternum are very rare tumors. We present herein the case of a patient who had a primary sternal tumor with solitary plasmacytoma and no evidence of multiple myeloma.

Surgical treatment of killian-jamieson diverticulum.

Killian-Jamieson diverticulum is a rare diverticular disease. This disease differs from Zenker's diverticulum in its location and mechanism. Various treatment modality have been attempted, but traditional surgical treatment has been recommended for a symptomatic Killian-Jamieson diverticulum due to the concern of possible nerve injury. We performed surgical treatment by cervical incision. We report here on a case of Killian-Jamieson diverticulum and we briefly review the relevant literature.

Granular cell tumor occurring in the chest wall: a case report.

Granular cell tumors are uncommon soft tissue neoplasm of nerve sheath origin, which are predominately benign. Granular cells can be found at any site in the body including the tongue, skin, subcutaneous tissue, breast, gastrointestinal, and urogenital systems. However, granular cell tumors have only been rarely described in the chest wall. Here we report a case of a granular cell tumor that occurred in the chest wall of a 59-year-old woman, along with a review of the literature.

Coronary-bronchial artery fistula manifested by hemoptysis and myocardial ischemia in a patient with bronchiectasis.

A coronary-bronchial artery fistula is a very rare congenital anomaly of the coronary artery whose etiology and pathogenesis have not yet been clarified. Most patients with coronary-bronchial fistulas are asymptomatic; however, some patients present with congestive heart failure, infective endocarditis, myocardial ischemia induced by a coronary steal phenomenon, or rupture of an aneurysmal fistula. Furthermore, patients with a coronary-bronchial artery fistula rarely manifest life-threatening hemoptysis due to the associated bronchiectasis. We report herein the case of a patient with a coronary-bronchial artery fistula who had bronchiectasis and a history of massive hemoptysis and myocardial ischemia.