Type A aortic dissection after 'zone 0' thoracic endovascular aortic repair for type 1 hybrid aortic arch replacement of arch aneurysm.

The recent rise in minimally invasive cardiovascular procedures is being accompanied by an increase in related complications. We report on an acute type A aortic dissection performed in an 82-year-old man 1 week after staged 'zone 0' hybrid thoracic endovascular aortic repair (TEVAR). Previously, the patient had undergone type I hybrid arch debranching and staged 'zone 0' TEVAR for an aortic arch aneurysm. 'Zone 0' TEVAR after type I hybrid debranching might increase the risk for aortic injury on the residual native aorta and should, therefore, be closely followed up to enable the early diagnosis of complications.

Electromagnetic navigation bronchoscopy-Chungnam National University Hospital experience.

BACKGROUND: To find small pulmonary nodules or ground grass nodules (GGNs) with video-assisted thoracoscopic surgery (VATS) is very difficult. There are several conventional methods to localize small nodules or GGNs, which require additional radiation exposure and may cause some complications such as pneumothorax or hemothorax. We aimed to evaluate the effectiveness and feasibility of electromagnetic navigational bronchoscopy-guided pulmonary localization in a minimally invasive thoracic surgery field. METHODS: We retrospectively reviewed the medical records from a prospectively collected database of the patients who underwent ENB procedure for biopsy and/or localization of pulmonary resection at the Chungnam National University Hospital from January 2017 to January 2018. RESULTS: A total of 37 ENB-guided dye-markings or biopsies for 37 lesions in 30 patients were performed. Thirty-two ENB-guided localizations using dye-marking for resection were performed in 25 patients. The median nodule size was 9 mm (IQR: 7-13 mm), and the median distance from the pleura was 6 mm (IQR: 3-10 mm). The failure of an ENB-guided localization was noted in 4 cases (12.5%). There was no major complication noted with the procedure, and just two patients showed mild intrabronchial bleeding stopped spontaneously. The most common lobar location was right lower lobe (11 cases, 34.4%), and all cases of localization failure were right lower lobe. A pathologic diagnosis was obtained from surgically resected specimen (not from ENB biopsy: 32 of 32 localizations, 100%), neoplastic lesions were 23 cases (72%). Of them, a primary lung cancer and metastatic lung cancer were noted in 11 cases, and in 11cases, respectively. All margins of the nodules were negative. CONCLUSIONS: The ENB-guided dye localization by a well-trained thoracic surgeon enables accurate intraoperative identification of GGN or a small pulmonary nodule, with minimal complications and enables minimally invasive surgery including single port surgery.

Result of surgical resection for pulmonary metastasis from urothelial carcinoma.

BACKGROUND: Treatment of pulmonary metastasis from urothelial cell carcinoma has been mostly palliative chemotherapy and the role of pulmonary metastasectomy has not been investigated much. MATERIALS AND METHODS: This study is a retrospective interim review of pulmonary metastasectomy from urothelial carcinoma at single institution between 1998 and 2010. Overall 16 patients underwent pulmonary metastasectomies. RESULTS: There was no postoperative complication or hospital mortality. Mean hospital stay was 6 days. Overall and disease-free 5-year survival were 65.3% and 37.5%, respectively. CONCLUSION: In selected patients with pulmonary metastasis from urothelial carcinoma, surgical treatment is feasible and could contribute to long-term survival in selected patients.

Acute Postpneumonectomy Empyema with Bronchopleural Fistula Treated with Vacuum-assisted Closure Device.

Postpneumonectomy empyema is a life-threatening complication, which is often related with a bronchopleural fistula. After surgical repair of fistula, sterilization of infected pleural cavity is important and usually carried out by long-term cyclic irrigation. We report a case in which vacuum-assisted closure device was successfully applied to sterilize the pleural cavity and obliterate bronchopleural fistula.

Pleural abrasion for mechanical pleurodesis in surgery for primary spontaneous pneumothorax: is it effective?

PURPOSE: Some patients with primary spontaneous pneumothorax suffer from recurrence of bullous lesions of the lung after resection. Mechanical pleurodesis by pleural abrasion is one of the standard procedures to prevent recurrence. However, there is actually little evidence that pleural abrasion reduces the recurrence of primary spontaneous pneumothorax. Our aim was to evaluate the efficacy of mechanical pleurodesis by pleural abrasion during thoracoscopic procedures for primary pneumothorax. METHODS: From January 2003 to December 2009, 263 patients underwent 294 initial thoracoscopic wedge resections with or without pleural abrasion for primary spontaneous pneumothorax at the Samsung Medical Center. Medical records of patients were reviewed retrospectively. RESULTS: Thirty-one patients were excluded from the study due to various comorbidities. The remaining 232 patients underwent 257 thoracoscopic wedge resections with (165) or without (92) pleural abrasion. No mortality was observed. Seven additional chemical pleurodesis and 3 reoperations were performed due to persistent air leakage after initial surgery. There were 18 instances of recurrence, and the overall recurrence rate was 7.1%. Twelve additional wedge resections were performed because of recurrence after initial surgery. The mean duration of postoperative pleural drainage was 2.86 days. There were no significant differences in the recurrence rate (P=0.9499), and duration of chest tube drainage (P=0.5200) between the patients with and without pleural abrasion. Younger patients, especially below 17 years of age, had significant risk of recurrence (P<0.0001). CONCLUSIONS: Thoracoscopic wedge resection alone successfully controlled primary spontaneous pneumothorax. Additional pleural abrasion did not decrease the recurrence of pneumothorax after wedge resection of bullae for primary spontaneous pneumothorax. Younger age was associated with higher risk of recurrence.

2009 H1N1 influenza virus infection and necrotizing pneumonia treated with extracorporeal membrane oxygenation.

A 3-year-old girl with acute respiratory distress syndrome due to a H1N1 2009 influenza virus infection was complicated by necrotizing pneumonia was successfully treated with extracorporeal membrane oxygenation (ECMO). This is the first reported case in which a pediatric patient was rescued with ECMO during the H1N1 influenza epidemic in Korea in 2009.

Mass reduction and functional improvement of the left ventricle after aortic valve replacement for degenerative aortic stenosis.

BACKGROUND: Left ventricular (LV) hypertrophy caused by aortic valve stenosis (AS) leads to cardiovascular morbidity and mortality. We sought to determine whether aortic valve replacement (AVR) decreases LV mass and improves LV function. MATERIALS AND METHODS: Retrospective review for 358 consecutive patients, who underwent aortic valve replacement for degenerative AS between January 1995 and December 2008, was performed. There were 230 men and 128 women, and their age at operation was 63.2±10 years (30~85 years). RESULTS: There was no in-hospital mortality, and mean follow-up duration after discharge was 48.9 months (2~167 months). Immediate postoperative echocardiography revealed that LV mass index and mean gradient across the aortic valve decreased significantly (p<0.001), and LV mass continued to decrease during the follow-up period (p<0.001). LV ejection fraction (EF) temporarily decreased postoperatively (p<0.001), but LV function recovered immediately and continued to improve with a significant difference between preoperative and postoperative EF (p<0.001). There were 15 late deaths during the follow-up period, and overall survival at 5 and 10 years were 94% and 90%, respectively. On multivariable analysis, age at operation (p=0.008), concomitant coronary bypass surgery (p<0.003), lower preoperative LVEF (<40%) (p=0.0018), and higher EUROScore (>7) (p=0.045) were risk factors for late death. CONCLUSION: After AVR for degenerative AS, reduction of left ventricular mass and improvement of left ventricular function continue late after operation.

Video-Assisted Thoracic Surgery (VATS) Lobectomy for Pathologic Stage I Non-Small Cell Lung Cancer: A Comparative Study with Thoracotomy Lobectomy.

BACKGROUND: Surgical treatment of stage I non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to evaluate the feasibility of VATS lobectomy for pathologic stage I NSCLC. MATERIAL AND METHODS: Between December 2003 and December 2007, 529 patients with pathologic stage I NSCLC underwent lobectomies (373 thoracotomy, 156 VATS). Patients in both groups were selected after being matched by age, gender and pathologic stage using propensity score method, to create two comparable groups: thoracotomy and VATS groups, and the overall survival, recurrence-free survival, complication and length of hospitalization were compared between these two groups. RESULTS: After the patients were matched by age, gender and pathologic stage, 272 patients remained eligible for analysis, 136 in each group (mean age of 59.5 years; 70 men, 66 women; 80 stage IA, 56 stage IB). There was no statistical difference in other preoperative clinical characteristics between the two groups. No hospital mortality was observed in both groups. Overall 3-year survival rate was 97.4% in thoracotomy group and 96.6% in VATS groups (p=0.76). During the follow-up, 20 patients (14.7%) developed recurrence in thoracotomy group, including loco- regional recurrence in 7, distant metastasis in 13. In VATS group, 13 patients (9.6%) developed recurrence, including loco-regional recurrence in 4, distant metastasis in 9. Three-year recurrence-free survival rate was 81.8% in thoracotomy group and 85.3% in VATS groups (p=0.43). There was no significant difference in postoperative complications between thoracotomy and VATS groups (30 cases in 22 patients vs. 19 cases in 17 patients, p=0.65, odds ratio=1.19). The mean hospital stay of VATS group was 2 days shorter than that of thoracotomy group (8.8±6.5 days vs. 6.3±3.3 days, p<0.05). CONCLUSION: VATS lobectomy for pathologic stage I lung cancer is a feasible operation with shorter hospitalization, while surgical outcome is comparable to thoracotomy lobectomy.

Neo-ostium Formation in Anomalous Origin of the Left Coronary Artery.

Anomalous origin of a coronary aortic artery is a rare cardiac anomaly. Although it can cause angina, syncope, and palpitations, most patients are asymptomatic. This anomaly requires surgical treatment or intervention because it is associated with sudden death. Several surgical techniques, such as coronary reimplantation, coronary artery bypass grafting (CABG), unroofing, and neo-ostium formation, have been proposed as treatments. We report a case surgically treated with neo-ostium formation in anomalous origin of the left coronary artery from the right coronary sinus.

Virologic response at 12 months of treatment predicts sustained antiviral efficacy in patients with adefovir-treated Lamivudine-resistant chronic hepatitis B.

BACKGROUND/AIMS: The aim of our study was to define the potential role of virologic response at 12 months of treatment (VR12) in predicting subsequent virologic and clinical outcomes in adefovir (ADV)-treated lamivudine-resistant chronic hepatitis B. METHODS: Two hundred and four patients with lamivudine-resistant chronic hepatitis B virus (HBV) treated with ADV monotherapy were included. Serum HBV DNA was quantified by real-time polymerase chain reactions. VR12 was defined as a HBV DNA level of less than 4 log(10) copies/mL after 12 months of ADV treatment. RESULTS: VR12 was observed in 110 of the 204 patients (54%). The mean HBV DNA reductions from baseline after 12 months of ADV treatment were 3.8 and 1.9 log(10) copies/mL in patients with and without VR12, respectively (p<0.001). The hepatitis B "e" antigen (HBeAg) seroconversion rates in patients with and without VR12 were 32% and 14% at 12 months treatment, respectively (p=0.018), and 40% and 27% at 24 months of treatment (p=0.032). The genotypic mutation rates to ADV in patients with and without VR12 were 0% and 6% at 12 months of treatment, respectively (p=0.033), and 21% and 42% at 24 months (p=0.012). The rates of viral breakthrough in patients with and without VR12 were 0% and 7% at 12 months of treatment, respectively (p=0.072), and 9% and 25% at 24 months (p=0.006). CONCLUSIONS: Patients without VR12 may need to switch to or add on other potent antiviral drugs in their medical regimens.

[Comparison of CTP, MELD, and MELD-Na scores for predicting short term mortality in patients with liver cirrhosis].

BACKGROUND/AIMS: MELD-Na (model for end-stage liver disease with incorporation of serum sodium) was suggested to provide better survival prediction than MELD alone for patients with end stage liver disease. However, there is no data verifying the usefulness of MELD-Na for predicting short term mortality of cirrhotic patients in Korea. This study was aimed to determine whether MELD-Na would be more accurate in predicting short term mortality than other scoring systems such as Child-Turcotte-Pugh (CTP) or MELD. METHODS: Data from 355 patients admitted due to liver cirrhosis were retrospectively reviewed. The cumulative survival rates were obtained. Prediction of mortality rate for three months and one year were analyzed using the area under the receiver's operating characteristics curve (AUC). RESULTS: One hundred patients (28%) died during the study period. All of the three systems showed significant differences in the cumulative survival rate according to the scores on admission (p0.001). The AUC of CTP, MELD, and MELD-Na in predicting three-months mortality were 0.828, 0.845, and 0.862 (p0.05), and the AUC of each score system for death within one year were 0.792, 0.800, and 0.831, respectively (p0.05). The AUC of MELD-Na in predicting short term death were the highest, although it was not statistically significant. Multivariate analysis showed that only MELD-Na was significantly related to three-month mortality (p=0.012). CONCLUSIONS: MELD-Na is more appropriate in predicting short term mortality, but larger scale studies are needed to confirm the superiority of MELD-Na to MELD and CTP in patients with liver cirrhosis.

[Clinical features of pseudoaneurysms complicating pancreatitis: single center experience and review of Korean literature].

BACKGROUND/AIMS: Pseudoaneurysm is a life-threatening complication of chronic or acute pancreatitis. This study was undertaken to evaluate the clinical features of pseudoaneurysm complicating pancreatitis. METHODS: We reviewed the medical records of 7 patients diagnosed as pseudoaneurysms with chronic pancreatitis in Korea University Guro and Anam Hospital from January 1995 to March 2006 and analyzed their demographics, clinical courses and outcomes. RESULTS: All patients were men and mean age was 54.6 years (range, 43-67 years). All the cases occurred in the setting of chronic alcoholic pancreatitis complicated by pseudocyst. Abdominal pain was the unique initial clinical symptom in 5 cases, hematemesis in 1 case, and simultaneous abdominal pain with hematemesis in 1 case. Bleeding into pseudocyst developed in 5 cases, flowing into duodenum through pancreatic duct in 1 case and rupture into the descending colon in 1 case. Mean duration between onset of symptom and diagnosis of pseudoaneurysm was 7.8 days (range, 1-23 days). Six cases were diagnosed by abdominal computed tomography disclosing characteristic finding of focal high density area in the pseudocyst. Pulsed doppler abdominal sonography was performed before computed tomography in 3 cases and results were negative in 2 cases. Transcatheter arterial embolizations were initially performed in 6 cases, and there was no recurrent bleeding except one case of splenic infarction. Distal pancreatectomy was initially performed in 1 case. CONCLUSIONS: Pseudoaneurysms complicating chronic pancreatitis shows various clinical features. Transcatheter arterial embolization can be recommended as a primary therapeutic modality.

[A case of vasculitis in chronic hepatitis C patient treated with pegylated interferon alpha-2a and ribavirin].

There has been an increase in the number of patients treated with pegylated interferon (PEG-IFN) and ribavirin due to the better antiviral efficacy. The main serious adverse events of PEG-IFN plus ribavirin combination therapy are bone marrow suppression and hemolytic anemia. However, there are few reports of vasculitis occurring during PEG-IFN therapy. We describe a patient who developed vasculitis during the treatment of chronic hepatitis C with PEG-IFN and ribavirin.

[A case of peripheral ischemic complication after terlipressin therapy].

Hepatorenal syndrome is a severe complication of cirrhosis, leading to death in more than 90% of cases in the absence of liver transplantation. Several treatments have been attempted as a bridge to liver transplantation. Among such treatments, terlipressin is a nonselective V1 vasopressin agonist. When comparing with ornipressin, it is known to have a similar vasoconstricting potency, but much less ischemic complication. We report a case of gangrene on toes and necrosis on the infusion site of left hand which developed after the use of terlipressin due to hepatorenal syndrome in a 41-year-old-man with liver cirrhosis. Ischemic complication of terlipressin is rare and there has been no case report in Korea. Although it is rare, we must pay attention to the peripheral ischemic complication of terlipressin.

[Comparison of the effectiveness of quadruple salvage regimen for Helicobacter pylori infection according to the duration of treatment].

BACKGROUND/AIMS: At present, triple therapy schemes are recommended by national and international consensus conferences for the treatment of Helicobacter pylori (H. pylori) infection. However, even with the most effective current treatment regimens, about 10-20% of patients fail to eradicate H. pylori, necessitating alternative strategy to eradicate H. pylori in primary treatment failure. Therefore, we performed this study to evaluate the efficacy of quadruple therapy and to compare 1 and 2-week quadruple regimen as a second-line therapy. METHODS: The hospital records of 155 patients who failed to the standard triple therapy (proton pump inhibitor, amoxicillin, clarithromycin) were reviewed retrospectively, and divided the 1 or 2 weeks OBMT regimen (omeprazole 20 mg bid, bismuth salt 120 mg qid, metronidazole 500 mg tid, tetracycline 500 mg qid). Presence of H. pylori infection and side-effects of the treatment regimen were assessed 4 weeks after the cessation of treatment. RESULTS: One hundred and eight male and 47 female (mean age, 52.2+/-15.4) patients were enrolled. The overall eradication rate of H. pylori with quadruple therapy was 83.9% and the eradication rate was similar between 1 and 2 weeks of OBMT regimen (76.8% in OBMT 1 week, 87.9% in OBMT 2 weeks, respectively p=0.110). CONCLUSIONS: Quadruple therapy is an effective salvage regimen for H. pylori eradication after the failure of standard triple therapy. One week quadruple therapy is not significantly different from 2-weeks regimen as the second-line option for H. pylori eradication.

[Spontaneous resolution of vanishing bile duct syndrome in Hodgkin's lymphoma].

Cholestasis in a patient with Hodgkin's disease is uncommon, and the causes of cholestasis are mainly direct tumor involvement of the liver, hepatotoxic effects of drugs, viral hepatitis, sepsis and opportunistic infections. Vanishing bile duct syndrome (VBDS) represents a very rare cause for cholestasis in this disease. We report here on a case of a 45-year-old man who developed VBDS during the complete remission stage of Hodgkin's lymphoma. There was no history of hepatitis or intravenous drug abuse, and the patient had negative results for hepatitis A virus, hepatitis B virus, hepatitis C virus, cytomegalovirus, and human immunodeficiency virus. The serological studies for antinuclear antibodies, anti-mitochondrial antibodies and anti-smooth muscle antibodies were also negative. Liver biopsy disclosed the absence of interlobular bile ducts in 9 of 10 portal tracts without any active lymphocyte infiltration and there were no Reed-Sternberg cell in the liver. The patient's cholestasis was in remission and the serum bililrubin level was normalized after two months without treatment, but tumor recurrence was noted at multiple sites of the abdominal lymph nodes on follow-up abdomino-pelvic computed tomogram.

[Efficacy of 14 day OBMT therapy as a second-line treatment for Helicobacter pylori infection].

BACKGROUND/AIMS: As a second-line treatment for H. pylori eradication in the case of first-line OAC (omeprazole, amoxicillin, clarithromycin) treatment failure, a minimum of one-week OBMT quadruple therapy composed of omeprazole, bismuth, metronidazole, tetracycline has been recommended in European countries and one or two weeks in USA. In Korea, one-week OBMT quadruple therapy is recommended for the case of first-line OAC treatment failure. Because H. pylori eradication rate of one-week OBMT therapy in Korea is about 80%, the eradication rate of one week therapy is not satisfactory. We analyzed the effect of two-week second-line OBMT therapy. METHODS: Between June 2002 and June 2003, 107 patients who were H. pylori positive (44 males and 63 females: mean age 51.8 years) after primary eradication therapy received two-week OBMT therapy. Four weeks after completion of therapy, 13C-urea breath test was performed to detect H. pylori. RESULTS: After two weeks of OBMT therapy, eradication was achieved in 103 of 107 patients (96.3%) and in 68 of 71 peptic ulcer patients (95.8%). CONCLUSIONS: Two-week OBMT therapy should be considered as a retreatment regimen with the eradication rate more than 90%.