Severe re-expansion pulmonary edema after chest tube insertion for the treatment of spontaneous pneumothorax: A case report.

RATIONALE: Re-expansion pulmonary edema (REPE) is a rare complication after chest tube insertion for the treatment of spontaneous pneumothorax. However, this complication can be life threatening when it occurs. Therefore, it is necessary to recognize REPE early and treat it appropriately. In the present study, we report a severe REPE case occurring after chest tube insertion in a patient with spontaneous pneumothorax. PATIENT CONCERNS: A 27-year-old male patient visited out hospital with chest pain on the left, which had started a week ago. After diagnosed with pneumothorax and having chest tube insertion, the patient complained of sudden shortness of breath, persistent cough, foamy sputum, and vomiting. DIAGNOSIS: Based on the symptoms and imaging findings, the patient was diagnosed as REPE. INTERVENTIONS: After the condition of the patient deteriorated rapidly, he was transferred to intensive care unit and then mechanical ventilation and conservative treatment were performed after endotracheal intubation. OUTCOMES: After mechanical ventilation and conservative treatment in the intensive care unit, the symptoms and radiological findings improved, and then mechanical ventilation was weaned and the chest tube was removed from the patient. However, due to recurrent pneumothorax after removal of the chest tube, video assisted thoracoscopic surgery (VATS) wedge resection was performed. At 6 months post-operative follow up, he was well with normal radiological findings. LESSONS: REPE occurs rarely, but once it does, it causes a serious condition that can be life-threatening. Therefore, patients with the risk factors related to it should receive a closed observation after chest tube insertion. Moreover, if REPE occurs, appropriate treatments should be carried out by recognizing it early.

Staged hybrid treatment for giant thrombosed fusiform aneurysm.

Partially thrombosed intracranial aneurysm was difficult to treat because of higher recurrence rate compared to non-thrombosed saccular aneurysm. The author reports a case of partially thrombosed intracranial aneurysm causing transient ischemic symptom. A 40-year-old man presented with transient right hemiparesis. Brain magnetic resonance imaging (MRI) depicted low-signal intensity target-like mass lesion on left sylvian fissure, and magnetic resonance angiography (MRA) showed aneurysm on left middle cerebral artery bifurcation (MCBF), suggested thrombosed aneurysm. On operative finding, aneurysm wall had thick and atherosclerotic change, and it was fusiform aneurysm not saccular type. We initially planned direct clip for the aneurysm, but it was failed due to collapse of parent artery after clipping on aneurysm neck. To prevent ischemia, extracranial-intracranial bypass was performed and then thrombectomy with clip reconstruction. To remodeling the fusiform aneurysm, stent-assisted coiling was performed for remnant portion of aneurysm. With staged hybrid technique, giant thrombosed fusiform aneurysm was completely obliterated and the patient did not suffer any neurologic symptoms no longer.

Efficacy and Safety of Emergency Extracranial-Intracranial Bypass for Revascularization within 24 Hours in Resolving Large Artery Occlusion with Intracranial Stenosis.

BACKGROUND: Endovascular treatment (EVT) is less effective for intracranial atherosclerosis-induced emergent large vessel occlusion. Extracranial-intracranial (EC-IC) bypass surgery is a possible treatment option to augment cerebral blood flow in the perfusion defect area. We compared the efficacy and safety of EC-IC bypass surgery with those of EVT and maximal medical treatment for acute ischemic stroke. METHODS: The data from 39 patients, for whom vessel revascularization had failed despite mechanical thrombectomy, were retrospectively analyzed. Of the 39 patients, 22 had undergone percutaneous transluminal angioplasty or intracranial stenting (PTA/S), 10 had undergone emergency EC-IC bypass surgery within 24 hours of symptom onset, and 7 had received maximal medical treatment (MMT) only. The patency, perfusion status, and postoperative infarct volume were evaluated. The clinical outcomes were assessed at 6 months postoperatively using the modified Rankin scale. RESULTS: The mean reperfusion time was significantly longer for the EC-IC bypass group (14.9 hours) compared with that in the PTA/S group (4.1 hours) and MMT group (7.5 hours; P < 0.05). The postoperative infarct volume on diffusion-weighted magnetic resonance imaging was significantly lower in the emergency EC-IC bypass group (11.3 cm3) than in the MMT group (68.0 cm3) but was not significantly different from that of the PTA/S group (14.0 cm3; P < 0.05). The proportion of patients with a modified Rankin scale score of 0-2 at 6 months after surgery was significantly higher in the EC-IC bypass group (80%) than in the PTA/S (59%) and MMT (14%) groups (P < 0.05). CONCLUSIONS: Emergency EC-IC bypass surgery is an effective and safe treatment option for intracranial atherosclerosis-induced acute ischemic stroke for which EVT is inadequate.

Tension gastrothorax in late-onset congenital diaphragmatic hernia, a rare but life-threatening condition: A case report.

RATIONALE: Tension gastrothorax is a serious condition that can cause acute respiratory failure, which is mostly related to congenital diaphragmatic hernia (CDH) in pediatric cases. It is uncommon in late-onset CDH patients, and is difficult to diagnose due to atypical presentation. It is often misdiagnosed as tension pneumothorax or pleural effusion, leading to delayed treatment and potentially fatal outcome. In this study, we are reporting our experience of diagnosis and treatment of tension gastrothorax in a late-onset CDH patient. PATIENT CONCERNS: A 2-year old boy presented to this hospital with severe dyspnea and abdominal pain that suddenly occurred while taking a bath. DIAGNOSIS: Based on radiological findings we diagnosed tension gastrothorax. INTERVENTIONS: Hernia reduction and diaphragmatic defect repair were performed under thoracotomy. OUTCOMES: After the operation, the patient's clinical symptoms and imaging findings improved. At 1-year postoperative follow up, the patient was well with normal chest x-ray findings. LESSONS: Tension gastrothorax in late-onset CDH is a life-threatening condition that requires rapid diagnosis and treatment. When the diagnosis is unclear by chest x-ray, chest computed tomography should be performed to confirm the diagnosis. A nasogastric tube should be inserted whenever possible for diagnosis and gastric decompression. Although laparotomy is the most preferred approach, we recommend that surgeons consider taking a thoracotomy approach in unstable patients that cannot undergo gastric decompression before operation.

Loss of ARID1A expression is associated with poor prognosis in non-small cell lung cancer.

Adenine-thymine-rich inactive domain-containing protein 1A (ARID1A) is a large subunit of the switch-sucrose nonfermenting (SWI-SNF) complex. ARID1A is considered to be a tumor suppressor in various cancers. We investigated the clinicopathological significance including prognosis of ARID1A expression in non-small cell lung cancer (NSCLC). ARID1A expression was studied by tissue microarray immunohistochemical analysis of 171 surgically resected NSCLC specimens including adenocarcinoma (ADC) and squamous cell carcinoma (SCC) on tissue microarray. Semiquantitative immunohistochemical score was obtained by multiplying the intensity and percentage scores. The overall score was further simplified by dichotomizing into either negative (score < 4) or positive (score ≥ 4) for each patient. The ARID1A-negative group revealed significantly higher correlations with male sex (p = 0.020), larger tumor size (p = 0.007), SCC than with ADC (p = 0.023) and smoking (p = 0.001). Univariate survival analysis showed that the ARID1A-negative group had a significantly shorter cancer specific survival than the ARID1A-positive group (p = 0.018). Multivariate survival analysis showed that ARID1A negativity (p = 0.022) were independent prognostic factors related with shorter cancer specific survival for NSCLC. In conclusion, Loss of ARID1A expression is a potential molecular marker to predictive of poor prognosis of NSCLC.

Repair of pectus carinatum, carinatum/excavatum complex patients with doubly double bar technique.

Surgical correction is needed for patients with pectus carinatum who do not adapt to bracing therapy. We performed the doubly double bar technique for ten patients who did not adapt to bracing therapy for patients with pectus carinatum and/or carinatum/excavatum complex type. A complete correction was achieved for all patients, and there were no complications. Our initial experience suggests that the doubly double bar technique can be performed effectively for pectus carinatum and/or carinatum/excavatum complex type patients.

Cuff Technique for Small-Diameter Vascular Grafts in the Systemic Arterial Circulation of the Rat.

This study determined the feasibility of the cuff technique for small-caliber vascular grafts in a rat model. A graft was implanted with the cuff technique or suture technique in a 1-cm segment of the abdominal aorta in 12 rats. The mean aortic clamp time was 29 minutes with the cuff technique and 44 minutes with the suture technique; the cuff technique was significantly shorter. Abdominal angiography at 1 week after implantation showed no significant stenosis in 9 rats, focal stenosis of the mid-portion of the graft in 1 rat with each technique, and total occlusion of the graft in 1 rat with the suture technique. We have successfully used the cuff technique for anastomosis for small-caliber vascular grafts in an animal model.

Surgical Outcomes of Double Compression and Complete Fixation Bar System in Pectus Excavatum.

BACKGROUND: Minimally invasive repair of pectus excavatum is a widely used technique for correction of pectus excavatum. Yet despite the advancement in the surgical techniques, it is still associated with various complications, including bar displacement leading to reoperation. To overcome this problem, we developed the double compression and complete fixation bar (DCCF) system that consists of 2 metal bars that are inserted above and below the sternum and compressed to correct pectus excavatum. METHODS: Patients who underwent pectus excavatum correction surgery at this center between April 2006 and March 2017 were divided into a DCCF system group and a conventional Nuss procedure group and their demographic, clinical, and surgical characteristics were compared. RESULTS: A total of 220 patients underwent the DCCF system procedure and 306 patients underwent the conventional Nuss procedure. The DCCF system group had significantly shorter operation time (p < 0.001) and postoperative hospital admission time (p < 0.001) compared with the conventional Nuss procedure group. There were only 2 cases (0.9%) of postoperative complications in the DCCF system group, which was significantly less than that of the conventional Nuss procedure group (n = 64, 20.9%; p < 0.001). In particular, there were no cases of bar displacement in the DCCF system group. CONCLUSIONS: The DCCF system was applied to surgical correction of pectus excavatum, which led to significant reduction in the operation time and postoperative hospital admission period, as well as reduced minimally invasive repair of pectus excavatum complication and bar displacement rates. Therefore, we recommend the application of the DCCF system to the surgical correction of pectus excavatum.

The usefulness of a trans-illuminated introducer during the Nuss procedure.

Background There has been an increase in the number of patients undergoing the Nuss procedure for cosmetic purposes, thus increasing the need for safer surgery. However, there are reports of massive hemorrhage and organ damage during the Nuss procedure which involves dissection of the anterior mediastinum. We have developed the trans-illuminated introducer that allows safe surgery while maintaining a small surgical incision of less than 1 cm. Methods This study was a retrospective review of 306 patients aged 3-40 years who underwent the Nuss procedure using the trans-illuminated introducer at our hospital between April 2006 and December 2014. Results There were 29 (9.5%) early postoperative complications. The most common early complication was pneumothorax (15 cases, 4.9%). Five (1.6%) patients developed hemothorax in the early postoperative period, which occurred independently of the dissection process of the anterior mediastinum. None of these patients required reoperation or blood transfusion. There were no complications caused by the introducer during dissection of the anterior mediastinum. Conclusions Using the trans-illuminated introducer, we were able to dissect the anterior mediastinum without a major complication, such as massive hemorrhage from the mediastinum, while maintaining a small surgical incision for cosmetic purposes. Therefore, we consider that the trans-illuminated introducer is useful for improving the outcome of the Nuss procedure.

Diagnosis and treatment of spontaneous pneumomediastinum: experience at a single institution for 10 years.

OBJECTIVE: The aim of this study was to identify appropriate method of diagnosis and treatment of spontaneous pneumomediastinum (SPM) based on our experience. METHODS: The medical records of patients who were diagnosed with SPM and treated at our hospital between April 2006 and July 2015 were, retrospectively, analyzed. The data included characteristics of the patients, method of diagnosis, treatment and clinical course. RESULTS: Forty-five patients were diagnosed with SPM and treated at our hospital. The mean age of patients was 18.96 ± 4.65 years and 35 patients were male. The main symptoms expressed by these patients were chest pain, throat pain or discomfort, and dyspnea. Nine patients had a precipitating event leading to SPM. Twelve patients had normal chest X-ray findings but were subsequently diagnosed with SPM on chest computed tomography (CT). Additional procedures including esophagogram (n = 36), bronchoscopy (n = 14) and endoscopy (n = 1) were done but none of patients were found to have organ damage. All patients received oxygen inhalation therapy. Oral intake was restricted in 36 patients and 43 patients received prophylactic antibiotics. The mean time taken for symptomatic improvement was 1.73 ± 0.85 days from diagnosis. The mean hospital stay was 3.93 ± 1.44 days and no patient developed recurrence of SPM during the follow-up period. CONCLUSIONS: In addition to chest X-ray, chest CT is recommended for accurate diagnosis of SPM. However, further invasive investigations, restriction of oral intake and the use of prophylactic antibiotics have minimal role in the diagnosis and treatment of SPM.

Can single-incision thoracoscopic surgery using a wound protector be used as a first-line approach for the surgical treatment of primary spontaneous pneumothorax? A comparison with three-port video-assisted thoracoscopic surgery.

OBJECTIVE: In this study, we compared single-incision thoracoscopic surgery (SITS) using a wound protector, with three-port video-assisted thoracoscopic surgery (VATS) to investigate whether it can be used as a first-line approach for primary spontaneous pneumothorax (PSP). METHODS: We retrospectively reviewed and analyzed the medical records of patients who were diagnosed with PSP in our hospital between March 2013 and January 2014 who underwent SITS (n = 37) or three-port VATS (n = 23). RESULTS: There was no significant difference between the patients who underwent SITS and those who underwent three-port VATS in terms of their age, gender, number of episodes, pneumothorax laterality, operation time, number of wedge resection, duration of post-operative hospital stay and post-operative drainage, and complications. The post-operative pain score was significantly lower in the SITS group compared to the three-port group at both 24 and 72 h (3.9 ± 1.2 vs. 5.2 ± 1.3, p = 0.022, 2.5 ± 1.5 vs. 3.9 ± 1.8, p = 0.03). There was no statistically significant difference in the use of additional intramuscular analgesia between the two groups, but it was lower in the SITS group. CONCLUSIONS: We consider that SITS using a wound protector is an appropriate first-line surgical approach for PSP.

The Role of Maximum Standardized Uptake Value in PET/CT as a Prognostic Factor in Patients with Resected Esophageal Squamous Cell Carcinoma.

BACKGROUND: The aim of this study was to evaluate the role of the maximum standardized uptake value (mSUV) of the main mass as a risk factor for recurrence in patients with completely resected esophageal squamous cell carcinoma (ESCC). PATIENTS AND METHODS: Clinicopathologic factors including primary tumor location, tumor size, depth of tumor invasion, number of positive lymph nodes, angiolymphatic invasion, and mSUV were analyzed as risk factors for recurrence. The prognostic influence of variables on disease-free survival was analyzed using the log-rank test for univariate analysis and the Cox proportional hazards model for multivariate analysis. RESULTS: A total of 102 patients underwent complete resection of ESCC and positron emission tomography/computed tomography was performed. The median follow-up period was 35.0 months (range, 2-94). The average mSUV of the main mass was 5.5 ± 4.2. The tumor had recurred in 38 patients (37.3%). Univariate analysis identified that tumor size (> 3.5 cm), depth of tumor invasion (≥ T2), pathologic stage, and mSUV (> 5.1) were statistically significant prognostic factors for recurrence of ESCC. However, in multivariate analysis, only mSUV (> 5.1, HR = 4.222, p = 0.025) was the independent risk factor of recurrence. CONCLUSIONS: The mSUV of the main mass was an independent predictor for recurrence with a cutoff value of 5.1.

Clinical application of single incision thoracoscopic surgery: early experience of 264 cases.

BACKGROUND: Single incision thoracoscopic surgery (SITS) is recognized as a difficult procedure and surgeons hesitate to perform this technique. We describe our experience of SITS and determine whether SITS can be a routine approach in minimally invasive surgery. METHODS: From May 2011 to April 2013, a single operator attempted SITS for 264 cases. Their medical records were retrospectively reviewed with regard to age, sex, diagnosis, operation time, hospital stay, need of additional incision, morbidity, and early outcome. RESULTS: A number of thoracic diseases and procedures were attempted with SITS including primary (n = 172) or secondary (n = 22) spontaneous pneumothorax, biopsy for lung (n = 29), pleura (n = 3), and mediastinal lymph node (n = 3), mediastinal mass excision (n = 11), empyema decortication (n = 11), lobectomy (n = 6), pulmonary metastasectomy (n = 3), pericardial window formation (n = 3), and hematoma evacuation (n = 1). Of these, 237 cases underwent SITS successfully. However, additional incision was needed in 10.2% (n = 27). Reasons for conversions were as follows: extensive pleural adhesion (n = 14), difficulty in endoscopic stapling (n = 11), bleeding (n = 1), and intolerance of one lung ventilation (n = 1). Conversion rate of empyema was 54.5%, which was the most difficult for SITS. In contrast, the conversion rate of PSP was 4.7%, which means PSP was the most applicable for SITS. Postoperative complications included air leak (≥ 3 days) (n = 1), wound problem (n = 4), delayed pleural effusion (n = 1), and postoperative bleeding (n = 1). CONCLUSIONS: SITS can be a routine approach from simple to more complicated diseases. However, we still have difficulties in cases with extensive pleural adhesion or location of lesion with difficult accessibility for endoscopic stapling.

Minimal invasive extrathoracic presternal compression using a metal bar for correction of pectus carinatum.

BACKGROUND: This report presents early results of surgical experience of minimal invasive extrathoracic presternal compression using a metal bar for correction of the pectus carinatum. METHODS: From February 2008 to February 2012, 15 patients with combined pectus carinatum and pectus excavatum underwent minimal invasive extrathoracic presternal compression using a metal bar for correction of pectus carinatum and Nuss operation for pectus excavatum. After 2 years, bar removal was done in all patients. In this paper, we focused on pectus carinatum repair. The effects and complications of the minimally invasive extrathoracic presternal compression using a metal bar for correction of pectus carinatum were reviewed. RESULTS: The median age was 15.7 years. The mean operation time for pectus carinatum with pectus excavatum was 122 min. The median length of hospitalization was 6 days. The Haller pectus index of pectus carinatum was 2.93 ± 0.36 pre-operatively and this was increased to 3.33 ± 0.61 post-operatively. There were no special complications. The degree of satisfaction of pectus carinatum correction was 3.75 ± 0.46 (range 1-4). CONCLUSION: Our results were favorable in spite of the small number of cases and short follow-up, and our modified technique of pectus carinatum was easy and simple. However, long-term follow-up is needed to accurately evaluate the effects of this surgery in many cases.

Prognostic factors for post-recurrence survival in patients with completely resected Stage I non-small-cell lung cancer.

OBJECTIVES: The clinical course from recurrence to cancer-related death after curative resection has not been clearly elucidated in non-small-cell lung cancer (NSCLC). This study examined the clinical outcomes after postoperative recurrence in patients with completely resected Stage I NSCLC. METHODS: This study included patients who had recurrence after complete resection for pathological Stage I NSCLC between 2003 and 2009. Clinical data evaluated in this study included the diagnostic process of recurrence, recurrence pattern, treatment process and prognosis. A number of clinicopathological factors were analysed for post-recurrence survival by univariate and multivariate analyses. RESULTS: Seventy-two patients experienced recurrence during a median follow-up period of 37.5 months. Thirteen patients (18%) presented symptoms at the initial recurrence. Tumour markers, computed tomography (CT) and positron emission tomography/CT were chosen as the initial diagnostic tools and detected recurrences in 1 (1%), 51 (71%) and 7 (10%) patients, respectively. The mean recurrence-free interval (RFI) was 15.4 months (≤12 months in 34, >12 months in 38 patients). The patterns of recurrence were presented as loco-regional recurrence in 36 (50%) and distant metastasis in 36 patients (50%). Types of the initial treatment included operations in 28 (39%), chemotherapy and/or radiotherapy in 38 (53%) and radiofrequency ablation in 2 patients (3%). Four patients (6%) rejected treatment. Forty-three patients (62%) presented a good response to the initial treatment. Thirty-seven patients (51%) died, and the cause of death in all of these patients was cancer-related. The median survival duration after recurrence was 43.6 (1-136) months. Univariate analysis identified no recurrence of symptoms, a good response to treatment and a longer RFI as good prognostic factors, while a good response to treatment and a longer RFI were independent prognostic factors in multivariate analysis. CONCLUSIONS: Most postoperative recurrences were detected in an asymptomatic condition during the routine follow-up period, and a good response to initial treatment and a longer RFI were significant predictors of better post-recurrence survival in patients with completely resected Stage I NSCLC.

Predictive factors for node metastasis in patients with clinical stage I non-small cell lung cancer.

BACKGROUND: Accurate clinical staging of non-small cell lung cancer (NSCLC) is essential for developing a treatment plan and evaluating suitability for minimally invasive surgery. The aim of this study was to evaluate predictive factors for metastasis of N1 and N2 nodes in clinical stage I NSCLC. METHODS: Records of patients with clinical stage I NSCLC who had undergone pulmonary resection with systematic node dissection or node sampling between 2003 and 2011 were retrospectively reviewed. To identify predictive factors for node metastasis, univariate and multivariate logistic regression analyses were performed. RESULTS: Among the 770 patients in this study, the overall prevalence of node metastasis was 19.4%, which included 11.3% of N1 nodes and 8.1% of N2 nodes. Predictive factors for N1 node metastasis included male sex, current smoker, non-adenocarcinoma, solid consistency, centrally located tumor, clinical T stage, cytokeratin fragment 21-1 level, tumor size, maximum standardized uptake value of the mass, and ground-glass opacity proportion. Adenocarcinoma, solid consistency, clinical T stage, carcinoembryonic antigen level, tumor size, and ground-glass opacity proportion were identified as predictors for N2 node metastasis. Both tumor size and solid consistency were independent predictive values of N1 node and N2 node metastasis by multivariate analysis. CONCLUSIONS: Among the patients with clinical stage I NSCLC, 19.4% of the patients showed unexpected node metastasis, and large size and solid consistency of the tumor were predictive factors of node metastasis in clinical stage I NSCLC. Preoperative staging should be performed more thoroughly to increase the accuracy of preoperative staging, especially in those who have the larger size and solid consistency of the tumor.

Prognostic factors of pulmonary metastasis from colorectal carcinoma.

OBJECTIVES: This study was conducted to investigate the prognostic factors of pulmonary metastases, focusing on the time of detection of pulmonary metastases related to adjuvant chemotherapy in patients with colorectal cancer (CRC). METHODS: Between June 2003 and December 2010, 84 patients underwent pulmonary metastasectomy for pulmonary metastasis (PM) from CRC. The clinicopathological data of colorectal surgery and pulmonary metastasectomy were analysed retrospectively. Disease-free intervals (DFIs) were specifically classified into the following three groups related to adjuvant chemotherapy after colorectal operation: Group 1, metastasis detected at initial presentation; Group 2, metastasis detected during adjuvant chemotherapy; Group 3, metastasis detected after completion of chemotherapy. The prognostic influence of these variables on disease-free survival was analysed using the log-rank test for univariate analysis and the Cox proportional hazards model for multivariate analysis. RESULTS: The median follow-up durations for patients after curative resection of CRC and pulmonary metastasectomy were 48.6 and 28.8 months, respectively. After pulmonary metastasectomy, recurrence was seen in 49 (58.3%) patients-pulmonary recurrence in 37 and extrathoracic recurrence in 12. Young age (<54 years old) at CRC operation, more than one PM, a DFIs of <12 months, detection synchronously or under adjuvant chemotherapy, and high CEA level before metastasectomy were worse prognostic factors by univariate analysis. From multivariate analysis, the number of pulmonary metastases (multiple metastases, HR=2.121, 95% confidence interval 1.081-4.159, P=0.029) and DFIs related with adjuvant chemotherapy (Group 1+2, HR=1.982, 95% confidence interval 1.083-3.631, P=0.027) were found to be independent predictors of disease-free survival. CONCLUSIONS: Disease-free intervals in association with the time of adjuvant chemotherapy and number of metastases were independent poor prognostic factors for pulmonary metastases from colorectal cancer.