Diverse clinical presentation of primary spontaneous pneumothorax in patients with pectus excavatum.

Objective: Patients with primary spontaneous pneumothorax (PSP) tend to be young, tall, and thin, as do those with pectus excavatum (PE). Notably, the Haller index, which measures the severity of PE, tends also to be higher in patients with PSP, further suggesting a potential predisposing factor for the development of PSP in individuals with PE. This study aimed to share clinical experiences with case series of concomitant PSP and PE and to emphasize the importance of evaluating these two conditions together. Methods: In this single-center study, we conducted a retrospective records review to identify patients who were diagnosed and treated (including surgical or conservative treatment and follow-up observation) for the diagnosis of PE between July 2011 and February 2023. From these, we selected patients who were diagnosed with both PE and PSP and analyzed their clinical presentations. Results: Among a total of 139 patients with PE, there were 8 (5.76%) who had concurrent diagnoses of PE and PSP and who underwent surgery for PSP, PE, or both. The average age of these 8 patients (male:female = 7:1) was 19.38 years. The 8 patients were grouped into four categories based on their clinical scenarios. Group A had 1 patient with PE diagnosed first, followed by the discovery of PSP during evaluation; Group B included 2 patients initially presenting with PSP and subsequently diagnosed with PE during evaluation; Group C consisted of 1 patient who had PSP before undergoing surgical PE correction; and Group D comprised 4 patients who developed PSP after PE correction. Conclusions: The incidence of PSP in patients with PE was 5.76% (8 out of 139 patients), indicating the importance of vigilant monitoring for PSP prior to PE surgery, and vice versa. Furthermore, the authors recommend close observation for PSP independent of PE surgery, even in the absence of postoperative complications.

Primary Perivascular Epithelioid Cell Tumor of the Lung: A Case Report.

Perivascular epithelioid cell tumors (PEComas) are very rare mesenchymal neoplasms, composed of histologically and immunohistochemically distinctive cells that form a sheet-like appearance around vessel lumens. Although most are benign, a malignant subset does exist, complicating clinical diagnostic efforts. Proper evaluation and management are thus essential for long-term patient survival. Herein, we present a rare case of a benign pulmonary PEComa that was diagnosed postoperatively in a 45-year-old woman.

Natural History of Contralateral Bullae/Blebs After Ipsilateral Video-Assisted Thoracoscopic Surgery for Primary Spontaneous Pneumothorax: A Retrospective Cohort Study.

BACKGROUND: Contralateral bullae/blebs are frequently found in patients who are scheduled to undergo ipsilateral video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax (PSP). RESEARCH QUESTION: Should visible contralateral bullae/blebs be simultaneously resected when ipsilateral VATS bullectomy is performed? STUDY DESIGN AND METHODS: In this single-center, retrospective cohort study, we included patients aged ≤ 30 years who underwent ipsilateral VATS for PSP from April 2009 to December 2019. Electronic medical records, radiograph images, and preoperative high-resolution CT images were reviewed. The primary end point was recurrence-free survival (no contralateral pneumothorax) after discharge of ipsilateral VATS for PSP, determined via Kaplan-Meier analysis. Recurrence was compared between the group with and that without contralateral bullae/blebs by using the log-rank test. A multivariable Cox proportional hazards model was constructed to investigate risk factors for contralateral pneumothorax. RESULTS: Among 567 patients, contralateral pneumothorax occurred in 86 of them after ipsilateral VATS (15.2%) during a median follow-up period of 51.3 (interquartile range, 67.2) months. The 1-, 5-, and 10-year recurrence-free survival rates were 92.2%, 83.7%, and 79.9%, respectively. Contralateral recurrence was higher in the group with (82/455, 18.0%) than in that without (4/112, 3.6%) contralateral bullae/blebs (P < .001). Age (hazard ratio [HR], 0.701; 95% CI, 0.629-0.780; P < .001), current smoking (HR, 2.106; 95% CI, 1.158-3.831; P = .015), and the presence of bullae/blebs (increasing with size, HR, 4.818-8.980; all P < .05) were independent risk factors for contralateral pneumothorax. The annual rates of contralateral pneumothorax in the group with (4.0%) and in that without (0.7%) contralateral bullae/blebs declined over time. INTERPRETATION: Although contralateral bullae/blebs were common in patients who underwent ipsilateral VATS for PSP and were statistically significantly associated with future pneumothorax, the annual rate of pneumothorax was 4.0% in such patients, and it decreased over time. Therefore, a conservative approach on unruptured contralateral bullae/blebs is recommended.

Thoracoscopic sympathetic block to predict compensatory hyperhidrosis in primary hyperhidrosis.

BACKGROUND: Compensatory hyperhidrosis is the main cause of patients' dissatisfaction following sympathectomy for primary hyperhidrosis. Therefore, thoracoscopic sympathetic nerve block before sympathectomy can be used to predict compensatory hyperhidrosis after sympathectomy. The objective of this study is to review our recent experience with the nerve block procedure, describing efficacy, safety and validity. METHODS: We retrospectively reviewed the medical records of 107 patients who underwent thoracoscopic sympathetic nerve block with a local anesthetic for primary palmar and craniofacial hyperhidrosis using a 2-mm needlescope from March 2017 to November 2019. A week later, the patients were interviewed, and a decision made as to whether to proceed with sympathectomy. We analyzed the perioperative data of patients who underwent the predictive procedure either followed, or not followed, by sympathectomy. RESULTS: Primary hyperhidrosis was relieved in all patients by the predictive procedure without severe complications. Compensatory hyperhidrosis happened to 32 patients (29.9%). Seventy-eight patients (72.9%) decided to undergo sympathectomy (group A) and 29 patients (27.1%) refused the sympathectomy (group B). Group B tended to have higher average body mass index (24.5 versus 23.2 kg/m2, P=0.082) and compensatory hyperhidrosis rate after predictive procedure (37.9% versus 26.9%, P=0.269) compared to group A. The compensatory hyperhidrosis rate after sympathectomy in group A was 76.9%. The effective duration of sympathetic block was significantly longer in group A than in group B (33.5 versus 13.9 hours, P=0.001). The predictive procedure had 94.4% specificity and 33.3% sensitivity for prediction of compensatory hyperhidrosis. CONCLUSIONS: Thoracoscopic sympathetic block may be safe and feasible as a procedure for predicting compensatory hyperhidrosis after sympathectomy, and beneficially, it allows the patients to experience the effect of sympathectomy on primary hyperhidrosis and occurrence of compensatory hyperhidrosis. However, a longer effective duration of sympathetic block is needed to help patients to decide whether to proceed with the surgery.

Bronchopleurobiliary fistula following right lower lobectomy in a patient with prior hepatic abscess: a case report.

In a 68-year-old male patient with cholangitis microabscess in the liver, cavitary lung cancer of the right lower lobe was incidentally diagnosed. The patient's medical history comprised totally laparoscopic distal gastrectomy (TLDG) and cholecystectomy 9 years ago. Before TLDG, endoscopic retrograde cholangiopancreatography (ERCP) was performed because of a common bile duct stone and cholangitis. Three months ago, he was readmitted with cholangitic microabscess, and a cavitary lesion of right lower lobe was detected incidentally. Hepatobiliary microabscess was improved with ERCP and antibiotic treatment. Video-assisted thoracoscopic surgery (VATS) right lower lobectomy and mediastinal lymph node dissection were undergone uneventfully. Pneumonic infiltration in the right lower lung field and hydropneumothorax on the right side were developed on postoperative day 10. Chest computed tomography showed pneumobilia and micro-bronchopleural fistula (BPF) was suspected with bronchoscopic examination. Despite antibiotics usage and thoracic suction, air leakage could not be improved. VATS Talc pleurodesis was performed on postoperative day 38. Contralateral pneumonia developed 1 week following talc pleurodesis. Furthermore, bilirubin was detected in the repeated bronchial washing and pleural fluid and they showed the same color and nature. Though ERCP and endoscopic nasobiliary drainage, the patient's condition deteriorated and the patient passed away on postoperative day 60. Bronchopleurobiliary fistula is an extremely rare complication after thoracic surgery for which surgical treatment is challenging, early recognition of a developing fistula and the aggressive treatment at an early stage can reduce the associated morbidity and mortality from the sequelae of this rare disease entity.

New bullae formation in the staple line increases the risk of recurrent pneumothorax following video-assisted thoracoscopic surgery bullectomy for primary spontaneous pneumothorax.

BACKGROUND: The study aimed to investigate the association between the recurrence of pneumothorax following video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax (PSP) and the formation of new bullae. METHODS: This retrospective review examined patients who underwent VATS for PSP between April 2009 and December 2014. Of the 415 operated lungs, high-resolution computed tomography (HRCT) scans of 85 were analyzed. RESULTS: Of the 85 HRCT scans examined, 21 (24.7%) were diagnosed with recurrent pneumothorax and 60 new bullae were found. In total, 39 new bullae were located in the staple line, 38 were at other sites far from the staplers, and 17 were concurrent in the stapling and non-stapling areas. The group with new bullae in staple line exhibited significantly higher recurrence rate following VATS than the groups with no new bullae in the staple line (P=0.000, log-rank test). Cox regression analysis revealed that new bullae formation in the staple line [hazard ratio (HR), 26.664; P=0.003] and the volume of a resected pathology specimen (HR, 1.032; P=0.020) were independent risk factors for pneumothorax recurrence. CONCLUSIONS: New bullae formation in the staple line increases the risk of recurrent pneumothorax following VATS. Thus, the current concept of VATS bullectomy-resect with sufficient margin-warrants reconsideration.

Prognostic prediction of clinical stage IA lung cancer presenting as a pure solid nodule.

BACKGROUND: Clinical stage IA lung cancer presenting as a ground glass opacity (GGO) on imaging is known to be associated with a good prognosis. Conversely, the prognosis of lung cancer presenting as a pure solid nodule is less favorable. The purpose of this study was to identify the predictive factors affecting prognosis in pure solid nodule lung cancer. METHODS: A total of 328 consecutive patients undergoing curative resection of clinical stage IA pure solid nodule lung cancer were reviewed retrospectively. Recurrence, survival and risk factors for nodal upstaging were analyzed. RESULTS: Of the 328 patients, 277 patients (84.6%) underwent lobectomy (or greater) and 51 patients (15.6%) underwent sublobar resection. Mediastinal lymph node dissection or sampling was performed in 278 patients (84.8%). The 5-year recurrence-free survival rate was 70.0% and the disease-specific survival rate was 86.5%. Intraoperative mediastinal lymph node dissection was the only significant related factor for recurrence and cancer-related death in a multivariate analysis [hazard ratio (HR) =0.485, P=0.020; HR =0.342, P=0.014]. A total of 217 patients underwent lobectomy with mediastinal lymph node dissection and nodal upstaging occurred in 36 patients (16.6%). There were no significant predictive factors for nodal upstaging in a multivariate analysis. Visceral pleural invasion, lymphovascular invasion, and small cell carcinoma histology were the only identified risk factors for nodal upstaging (HR =3.858, P=0.006; HR =8.792, P<0.001; HR =45.908, P=0.017). CONCLUSIONS: There were no definite factors predictive of prognosis in clinical stage IA pure solid nodule lung cancer. Only accurate pathologic staging and adequate intraoperative lymph node dissection were shown to be related to prognosis.

Right Main Bronchus Rupture Presenting with Pneumoperitoneum.

We report the case of a 16-year-old male patient who was involved in a traffic accident and transferred to the emergency department with mild chest pain. We initially did not find evidence of tracheal injury on computed tomography (CT). Within an hour after presentation, the patient developed severe dyspnea and newly developed subcutaneous emphysema and pneumoperitoneum were discovered. Abdominal CT showed no intra-abdominal injury. However, destruction of the right main bronchus was identified on coronal images of the initially performed CT scan. Emergency exploratory surgery was performed. The amputated right main bronchus was identified. End-to-end tracheobronchial anastomosis was performed, and the patient recovered without any complications.

Influence of lung resection volume on risk of primary spontaneous pneumothorax recurrence.

BACKGROUND: Thoracoscopic stapled bullectomy is a popular procedure for the treatment of primary spontaneous pneumothorax (PSP) that has a relatively high postoperative recurrence rate. One reason for PSP recurrence is the formation of a new bulla around the staple line. We hypothesized that different resected specimen volumes might cause differences in staple line tension. In this study, we analyzed the relationship between postoperative pneumothorax recurrence and resected lung volume. METHODS: Between April, 2009 and December 2013, 360 cases which underwent video-assisted thoracoscopic surgery (VATS) for PSP were selected. Recurrence after VATS was examined by electronic medical records and telephone survey. Resected volume and vertical area of specimen were calculated with the size of pathologic specimen. RESULTS: A mean follow up period was 44.5±24.4 months and recurrence rate was 11.1% (40/360). Large volume of resected specimen (≥16 cm3) (P=0.027 by the log-rank test) and larger vertical area of resected specimen (≥2.0 cm2) (P=0.003 by the log-rank test) showed significantly high recurrence rate. Cox regression analysis demonstrated that age [hazard ratio (HR), 0.083, P=0.006], vertical section area of resected specimen (HR, 1.239, P=0.020) and volume of resected pathology specimen (HR, 1.039, P=0.009) were independent risk factors of recurrence. CONCLUSIONS: Bulky resection during VATS for PSP increases the risk of recurrence. Large volume and vertical area of resected specimen are associated with greater tension in stapling line. Avoidance of wide resection and the firing of stapler after full collapse of lung are recommended for reducing the pneumothorax recurrence after VATS.

A chest tube misplaced in the heart?

A 69-year-old patient with a malignant right pleural effusion experienced an inadvertent chest tube insertion through the hepatic vein, which ended up in the right ventricle. This rare complication occurred using a 14-Fr Thal-Quick chest tube (Seldinger method). The chest tube was successfully removed in a non-operative approach.

Disseminated intravascular coagulopathy caused by type II endoleak after endovascular aneurysm repair in severe aortic stenosis.

A 72-year-old man with severe aortic stenosis (AS) presented with a type II endoleak after endovascular aneurysm repair (EVAR). Laboratory findings were consistent with disseminated intravascular coagulopathy (DIC) with thrombocytopenia. The platelet count increased slightly after aortic valve replacement but fully recovered with the reversal of DIC after surgical repair of the type II endoleak.

Management of right main bronchial rupture with a double lumen endotracheal tube in a patient with blunt chest trauma.

Tracheobronchial disruption is one of the most severe injuries caused by blunt chest trauma. It may cause airway obstruction and resulting life-threatening respiratory deficiency. However, the clinical presentations are variable and frequently difficult to diagnose. We report a case of a previously healthy 16-year-old man with complete right main bronchial transection sustained after a vehicular accident, who had progressive dyspnea, subcutaneous emphysema in the neck and anterior chest wall, and bilateral tension pneumothorax. Prompt chest tube drainage for suspected bilateral tension pneumothorax and a tracheal intubation were performed. Shortly after the positive pressure ventilation, severe subcutaneous emphysema developed and he was at risk for developing shock. Additional chest tubes were inserted. An emergency bronchoscopy showed rupture of the right main bronchus. After changing to a double lumen endotracheal tube, the patient's condition improved. A surgical closure was performed and postoperative bronchoscopy showed good repair. The patient was discharged without complications.

Low grade myxofibrosarcoma in the right ventricle presenting as pulmonary thromboembolism.

We report an unusual malignant cardiac neoplasm that initially presented as pulmonary thromboembolism in a 78-year-old male. Despite anticoagulation, the pulmonary artery lesion progressed and a mass-like lesion developed in the right ventricular outflow tract. Venoarterial extracorporeal membrane oxygenation was applied before surgery due to the presence of severe right-side heart failure with pulmonary hypertension. A round mass was found in the right ventricle and separate lobulated masses were found in both pulmonary arteries, and these were consistent with low-grade myxofibrosarcoma.

Costal exostoses as an unusual cause of spontaneous hemothorax.

A 20-year-old male presented with chest pain lasting several days. A radiologic examination revealed pleural effusion in the right hemithorax. Video-assisted thoracoscopic surgery demonstrated a bleeding focus at the diaphragm caused by injury due to a costal exostosis.

Anemia resolved by thoracoscopic resection of a mediastinal mass: a case report of unicentric Castleman's disease.

Castleman's disease (CD) is an uncommon benign lymphoproliferative disorder that usually presents as a single or multiple mediastinal mass. In unicentric CD, constitutional symptoms are rare, but are curable with surgical resection. However, serious intraoperative bleeding often requires conversion to thoracotomy. We present a case of unicentric CD in a 25-year-old woman with anemia, who was successfully treated by thoracoscopic resection. We describe the clinical course from the initial presentation to diagnosis and surgical cure.

Congenital tracheobiliary fistula in an adolescent patient.

Congenital tracheobiliary fistula is a rare malformation that allows communication between the respiratory system and hepatobiliary tract. We describe a male adolescent patient who was admitted with a destroyed lung caused by repetitive bile pneumonitis with a congenital tracheobiliary fistula. Left pneumonectomy was performed, and the fistula tract was successfully divided.

Calcified amorphous tumor in left atrium presenting with cerebral infarction.

Calcified amorphous tumor (CAT) of the heart is an extremely rare cardiac mass. We describe a case of cardiac CAT in a 70-year-old Korean female who presented with acute onset dysarthria and right side weakness. Echocardiography and chest computed tomography revealed a left atrial mass that originated from the interatrial septum. The patient underwent surgical resection and pathologic examination demonstrated CAT. Postoperative course was uneventful and she was followed without recurrence.

Prognostic factors affecting survival of patients with cancer-related pericardial effusion managed by surgery.

BACKGROUND: Although pericardial effusion (PE) is not uncommon in patients with cancer, it may lead to cardiac tamponade, a life-threatening condition. Prompt life-saving treatment is essential, and also allows the continuation of the cancer treatment. The aim of this study was to determine the prognostic factors for survival in patients with cancer who were treated surgically for PE. METHODS: We retrospectively reviewed the medical records of 55 patients with cancer with PE between January 2003 and October 2012, who were treated with a pericardial window operation. Overall survival (OS) was estimated from the date of surgery, and patients were followed until the time of the final visit or time of death. Clinical outcomes and candidate prognostic factors were analyzed. RESULTS: The median age of patients was 57 years (range 29 to 82 years), and 31 patients (56.4%) were male. The most common primary malignancy was lung cancer (65.5%), followed by breast cancer (10.9%). Fifteen patients (27.3%) developed recurrence of PE after surgery. The median OS duration was 4 months (range 0 to 39 months). Multivariate analysis found that evidence of pericardial metastasis on preoperative imaging (P = 0.029) and confirmation of malignant cells in the PE and/or pericardial tissue (P = 0.034) were associated with reduced OS. CONCLUSION: Evidence of pericardial metastasis on preoperative imaging and cytopathologic confirmation that the PE and/or pericardial tissue are positive for malignant cells can be used to predict poor clinical outcomes in patients with cancer-related PE.

Nodular fasciitis on chest wall in a teenager: a case report and review of the literature.

We report the case of a 16-year-old boy with a rapid growing mass on his left anterior chest wall. The mass was completely resected, and pathological examination confirmed nodular fasciitis. Benign chest tumors rarely occur in childhood. Nodular fasciitis is a benign proliferation of myofibroblast that is often mimicked by a sarcoma of the soft tissue. Physicians should consider the possibility of nodular fasciitis in chest wall tumors in the pediatric population.

Delayed-onset hypovolemic shock after the Nuss procedure for pectus excavatum.

The Nuss procedure, which is a minimally invasive approach for treating pectus excavatum, has better functional and cosmetic outcomes than other invasive procedures. Cardiac perforation is the most serious complication and several methods for the prevention of intraoperative events has been developed. Although most cardiac injuries are detected in the operating room, in the case described herein the patient experienced sudden hypovolemic shock during the postoperative recovery period. This indicates that special caution is mandatory even after successful execution of the Nuss procedure.