Long-term outcome of minimally invasive thymectomy versus open thymectomy for locally advanced cases.

OBJECTIVES: Our goal was to compare the oncological outcomes and efficacy between minimally invasive thymectomy (MIT) and open thymectomy (OT) in patients with early or locally advanced thymoma using a multicentre study database. METHODS: We retrospectively collected data from 1,239 patients who underwent thymectomy between January 2000 and December 2013, as recorded in the database of the Korean Association for Research on Thymus. We compared the postoperative outcomes of the MIT and OT groups using unmatched and propensity score (PS) matched data. RESULTS: We excised the thymoma using MIT and OT in 455 and 784 patients, respectively. We matched 378 patients with Masaoka-Koga stage I or II thymoma by their PS. The operative time, duration of hospital stay and complications were significantly shorter in the MIT group than in the OT group (all P < 0.005). In the PS matched data, the groups did not show significant differences in the 10-year survival rate (87.7% in OT vs 85.5% in MIT, stage II, mean follow-up duration: 12.9 years in OT vs 11.1 years in MIT), recurrence-free survival (94.0% in OT vs 86.4% in MIT) and R0 resection (97.35% in OT and MIT, P = 0.59). CONCLUSIONS: Compared with OT, MIT was associated with shorter operative times, shorter durations of hospital stay and fewer complications. Long-term survival, recurrence-free survival and complete resection were not significantly different between the OT and MIT groups. Our findings may help physicians track the progress of patients with early or locally advanced thymomas and design treatment plans for them.

Fentanyl versus Remifentanil for Cough Suppression and Recovery after Video-Assisted Thoracic Surgery.

BACKGROUND: Various methods have been used to reduce postoperative pain after thoracic surgery. However, these methods may affect the patient's respiratory response and delay recovery from anesthesia. We aimed to evaluate the effects of fentanyl and remifentanil during extubation after video-assisted thoracic surgery (VATS). METHODS: This study included 45 randomly-selected male patients who underwent VATS for pneumothorax between July 2011 and August 2012. We divided the participants into 3 groups: the F group, which received a bolus injection of 1.0 µg/kg of fentanyl; the R1 group, which received a 0.04 µg/kg/min remifentanil infusion; and the R2 group, which received a 0.08 µg/kg/min remifentanil infusion. Hemodynamics, pain, cough, consciousness level, and nausea were assessed for each group. RESULTS: The number and severity of coughs were lower in the R1 and R2 groups than in the F group, and there were no differences between the R1 and R2 groups. Respiratory depression and loss of consciousness were not observed in any of the patients, and there were no differences in hemodynamics. CONCLUSION: In comparison with fentanyl, remifentanil did not result in a wide fluctuation of blood pressure and heart rate upon emergence from general anesthesia. Moreover, remifentanil contributed to cough suppression and postoperative pain control. Remifentanil seems to be a safe and effective analgesic after VATS.

Acute Type A Aortic Dissection in a Patient with Situs Inversus Totalis.

We describe the occurrence of acute type A aortic dissection in a patient with situs inversus totalis. A 37-year-old man presented to the emergency department with acute chest pain. Initial chest X-ray findings showed a right-sided heart and a left-sided liver. Contrast- enhanced computed tomography revealed a Stanford type A acute aortic dissection, aortic root dilatation, and situs inversus totalis. All of the thoracic structures were mirror-image reversed and an abnormal coronary artery was observed. The Bentall operation was performed. This report demonstrates that computed tomography and echocardiography were useful for understanding the anatomy and the presence or absence of concurrent anomalies in a patient with situs inversus totalis. The patient's postoperative course was uneventful.

A 31-year-old pericardial textiloma.

Gossypibomas are uncommon but important complications of surgery. This case report is of a gossypiboma found accidentally 31 years after heart surgery. A 41-year-old man had lost 5 kg in the previous three months and suffered from intermittent epigastric discomfort. A computed tomography scan incidentally revealed a well-defined mass in the right lower anterior mediastinum. Given his history of previous cardiac surgery to repair a ventricular septal defect, the possibility of gossypiboma could not be excluded. Elective excision of the mass was performed through a median sternotomy, and a 5-cm ovoid mass consisting of a thrombus and gauze was removed. The postoperative course was uneventful. The patient's clinical findings were normal, with no abnormal findings on transthoracic echocardiogram performed one year later.

Array Comparative Genomic Hybridization as the First-line Investigation for Neonates with Congenital Heart Disease: Experience in a Single Tertiary Center.

BACKGROUND AND OBJECTIVES: The purpose of the present study was to investigate the advantages and disadvantages of verifying genetic abnormalities using array comparative genomic hybridization (a-CGH) immediately after diagnosis of congenital heart disease (CHD). METHODS: Among neonates under the age of 28 days who underwent echocardiography from January 1, 2014 to April 30, 2016, neonates whose chromosomal and genomic abnormalities were tested using a-CGH in cases of an abnormal finding on echocardiography were enrolled. RESULTS: Of the 166 patients diagnosed with CHD, 81 underwent a-CGH and 11 patients (11/81, 13.5%) had abnormal findings on a-CGH. 22q11.2 deletion syndrome was the most common (4/11, 36.4%). On the first a-CGH, 4 patients were negative (4/81, 5%). Three of them were finally diagnosed with Williams syndrome using fluorescent in situ hybridization (FISH), 1 patient was diagnosed with Noonan syndrome through exome sequencing. All of them exhibited diffuse pulmonary artery branch hypoplasia, as well as increased velocity of blood flow, on repeated echocardiography. Five patients started rehabilitation therapy at mean 6 months old age in outpatient clinics and epilepsy was diagnosed in 2 patients. Parents of 2 patients (22q11.2 deletion syndrome and Patau syndrome) refused treatment due to the anticipated prognosis. CONCLUSIONS: Screening tests for genetic abnormalities using a-CGH in neonates with CHD has the advantage of early diagnosis of genetic abnormality during the neonatal period in which there is no obvious symptom of genetic abnormality. However, there are disadvantages that some genetic abnormalities cannot be identified on a-CGH.

Limited thymectomy as a potential alternative treatment option for early-stage thymoma: A multi-institutional propensity-matched study.

OBJECTIVES: For early-stage thymoma, complete thymectomy has classically been regarded as the standard treatment protocol. However, several studies have shown that limited thymectomy may be an alternative treatment option for thymoma. This study compared perioperative outcomes, survival, and recurrence rates between patients undergoing limited thymectomy and complete thymectomy. MATERIALS AND METHODS: Between January 2000 and December 2013, a total of 762 patients underwent thymectomy for stage I or II thymomas at four institutions participating in the Korean Association for Research on the Thymus. Patients were divided into two groups: limited thymectomy group (n=295) and complete thymectomy group (n=467). Comparative clinicopathological, surgical, and oncological features were reviewed retrospectively. RESULTS: The median follow-up time was 49 months (range: 0.2-189 months). A propensity score-matching analysis, based on seven variables (age, sex, surgical approach, tumor size, WHO histological type, Masaoka-Koga stage, and adjuvant radiotherapy), was performed using 141 patients selected from each group. The 5- and 10-year freedom-from-recurrence rates in the limited thymectomy group were 96.3% and 89.7%, respectively, and those in the complete thymectomy group were 97.0% and 85.0%, respectively. No significant differences in these rates were observed between groups (p=0.86). A multivariate Cox regression analysis showed that overall survival and freedom-from-recurrence rates did not significantly differ by surgery extent (p=0.27, 0.66, respectively). Perioperative outcomes were better in the limited thymectomy group. CONCLUSION: Limited thymectomy was not inferior to complete thymectomy with respect to recurrence, and had better perioperative outcomes. Limited thymectomy may be a viable treatment option for early-stage thymoma.

Clinical results of sublobar resection versus lobectomy or more extensive resection for lung cancer patients with idiopathic pulmonary fibrosis.

BACKGROUND: Lung cancer patients with idiopathic pulmonary fibrosis (IPF) are at a high risk of requiring lung resection. The optimal surgical strategy for these patients remains unclear. This study aimed to compare the clinical results of a sublobar resection versus a lobectomy or more extensive resection for lung cancer in patients with IPF. METHODS: From January 1995 to December 2012, 80 patients with simultaneous non-small cell lung cancer and IPF were treated surgically at Asan Medical Center. Predictors of recurrence-free survival and overall survival were evaluated in the series. RESULTS: Lobectomy or more extensive resection of the lung (lobar resection group) was performed in 65 patients and sublobar resection (sublobar resection group) was carried out in 15 patients. The sublobar resection group showed fewer in-hospital mortalities than the lobar resection group (6.7% vs. 15.4%; P=0.68). For late mortality after lung resection, cancer-related deaths were not significantly different in incidence between the two groups (55.6% vs. 30.6%; P=0.18). Recurrence-free survival after lung resection was significantly greater in the lobar than in the sublobar resection group (P=0.01). However, overall survival after lung resection was not significantly different between the two groups (P=0.05). Sublobar resection was not a significant predictive factor for overall survival (hazard ratio =0.50; 95% CI: 0.21-1.15; P=0.10). CONCLUSIONS: Although not statistically significant, a sublobar resection results in less in-hospital mortality than a lobar resection for lung cancer patients with IPF. There is no significant difference in overall survival compared with lobar resection. A sublobar resection may be another therapeutic option for lung cancer patients with IPF.

Clinical results of surgical resection of mediastinal teratoma: efficacy of video-assisted thoracic surgery.

BACKGROUND: In patients with a mediastinal tumor, video-assisted thoracic surgery (VATS) is considered to be associated with more postoperative advantages compared to open procedures. However, open procedures are still preferred in cases with large or malignant tumors. Therefore, in order to determine the appropriate surgical strategies for resection of teratomas, we here review our experience with such cases. METHODS: Between January 2000 and February 2014, we experienced 132 patients diagnosed with mediastinal teratoma. By using data from a retrospective review of the patients' medical records, we compared the demographic characteristics, hospital stay duration, chest tube indwelling time, operative time, and mass size of the VATS group with those of the patients in the open group. Moreover, we also analyzed the postoperative complications and recurrence. Finally, based on our findings, we created a '∆V (volume of the mass-volume of the cyst in the mass)' capable of determining the appropriate surgical strategy, measured by preoperative computed tomography scan. RESULTS: We excised the mass using VATS in 79 patients, while 53 patients underwent open procedures, including thoracotomy (n = 10) and median sternotomy (n = 43). The operative times, the hospital stay duration, and the chest tube indwelling time were significantly shorter in the VATS group compared to in the open group (Table 1). Four cases were converted to thoracotomy. The mean mass sizes were 6.53 ± 2.20 cm and 8.58 ± 3.45 cm in the VATS and open groups, respectively. The '∆V' of the VATS group was higher than that of the open group. There were three postoperative complications. Table 1 Comparison of the perioperative variables between the VATS group and open groups VATS (n = 79) Open (n = 53) p value Preoperative variables Age (years) 32.34  ±  13.44 29.30 ± 14.76 0.223 Female 63 28 0.001 BMI 22.07 ± 3.34 22.59 ± 3.91 0.409 ASA class 0.272 Class 1 39 21 Class 2 40 32 Mass size (cm) 6.53 ± 2.20 8.58 ± 3.45 <0.001 ∆V (cm(3)) 988.15 ± 1590.85 3093.22 ± 4947.33 0.001 Intraoperative variable Operative time (min) 129 ± 46 170 ± 45 <0.001 Postoperative variable Hospitalization (days) 6.00 ± 3.03 8.94 ± 3.99 <0.001 ICU stay (days) 0 0.42 ± 0.50 <0.001 CTD time (days) 2.00 ± 1.24 3.8 ± 3.63 <0.001 Median F/U duration (months) 47.16 ± 43.60 27.52 ± 34.00 The data are presented as mean ± standard deviation VATS video-assisted thoracic surgery, CTD chest tube indwelling CONCLUSION: VATS for mediastinal teratoma can be performed safely in selected patients with large or malignant masses. The proposed '∆V' appears to be a useful method for determining the appropriate surgical strategy in the large size teratoma cases.

A comparison of the proposed classifications for the revision of N descriptors for non-small-cell lung cancer.

OBJECTIVES: Several new classifications have been proposed for revision of the N descriptors for non-small-cell lung cancer (NSCLC), but external validation is required. The aim of this study was to validate various newly proposed nodal classifications and to compare the discrimination abilities of these classifications. METHODS: A retrospective analysis was conducted of 1487 patients who underwent complete resection with systematic lymph node dissection for NSCLC between 2000 and 2008. Four nodal classifications based on the following categories were analysed: zone-based classification (single-zone N1, multiple-zone N1, single-zone N2 and multiple-zone N2), number-based classification (the number of metastatic lymph nodes; 1-2, 3-6 and ≥7), rate-based classification (ratio of the number of metastatic lymph nodes to the total number of resected lymph nodes; ≤15, 15-40 and >40%) and the combination of location- and number-based classification (N1: 1-3, N1: ≥4, N2: 1-3 and N2: ≥4). Concordance (C)-index and net reclassification improvement (NRI) index were used to assess the discrimination abilities of the models. RESULTS: In multivariate analysis, all of the newly proposed classifications were independent predictors (P < 0.001) of overall survival (OS) after adjustment for significant variables (age, tumour histology and pathological T status). The C-indices of the classifications based on the nodal zone, nodal number, rate and location alongside the number of metastatic lymph nodes were 0.6179, 0.6280, 0.6203 and 0.6221, respectively; however, the differences in the C-indices were statistically insignificant. Compared with the zone-based classification, the NRI for OS of classifications based on the nodal number, rate and location with number were 0.1101, 0.0972 and 0.0416, respectively. CONCLUSIONS: All four proposed classifications based on the nodal zone, nodal number, rate and the combination of location and number are prognostically valid and could serve as future N descriptors after complete resection of NSCLC. The discrimination ability was not significantly different among the four proposed classifications, although the number-based classification tended to have a higher predictive ability compared with the zone-based classification. Future studies with an in-depth discussion are needed to clarify optimal future N descriptors for NSCLC.

Long-Term Outcomes of the Maze Procedure Combined With Mitral Valve Repair: Risk of Thromboembolism Without Anticoagulation Therapy.

BACKGROUND: Although the strongest benefit of a concomitant Maze procedure during mitral valve repair is the obviation of the need for anticoagulation therapy, the risk of thromboembolism without anticoagulation therapy has not been evaluated. METHODS: A total of 362 consecutive patients (aged 52.2 ± 13.8 years, 180 females) who underwent the Maze procedure combined with mitral valve repair between 1997 and 2012 were evaluated. Anticoagulation therapy was discontinued after 6 months if synchronous atrial contraction was maintained in the absence of further risks of thromboembolism. RESULTS: The median follow-up period was 5.4 years (interquartile range, 2.9 to 9.6 years). Late atrial fibrillation (AF) occurred in 62 patients (17.1%). The 5-year freedom from AF off anti-arrhythmic drugs was 82.6% ± 2.3%. In 96 patients (26.5%), warfarin was administered in the late period (>6 months), and of them, 54 patients (14.9%) were maintained with warfarin therapy until the end of the follow-up. Patients receiving warfarin therapy were older (p = 0.030), had longer AF duration (p = 0.012), and had rheumatic valvulopathy more frequently (p = 0.003) compared with those not receiving warfarin. Overall, patients were followed up off the warfarin therapy for 1,577 patient-years, during which there were 4 cases of stroke or transient ischemic accident and 21 late deaths. The linearized rates of thromboembolic event and death without warfarin therapy were 0.06% and 0.12% per patient-year, respectively, and these rates were not significantly different from those receiving warfarin therapy. CONCLUSIONS: Adopting appropriate selection criteria for discontinuing anticoagulation therapy, the majority of patients receiving concomitant mitral repair and the Maze procedure can discontinue warfarin with excellent long-term safety profiles.

Schwannoma of the heart.

We present a case of a 55-year-old woman who complained of chest pain at rest. A mass was detected adjacent to her left atrium. The mass was completely excised, and a pathologic examination revealed it to be a schwannoma. Schwannomas are tumors that originate in the nerve sheath and are rarely detected in the heart. Here, we describe a rare case of primary schwannoma of the left atrium.

Influence of radiologically evident residual intimal tear on expansion of descending aorta following surgery for acute type I aortic dissection.

BACKGROUND: Although a residual intimal tear may contribute to the dilatation of the descending aorta following surgical repair of acute type I aortic dissection (AD), its causal relationship has not been elucidated by clinical data due to the limited resolution of imaging modalities. METHODS: This study enrolled 41 patients (age, 55.2±11.9 years) who were evaluated with dual-source computed tomography (CT) imaging of the whole aorta in the setting of the surgical repair of acute type I AD. Logistic regression models were used to determine the predictors of a composite of the aortic aneurysm formation (diameter >55 mm) and rapid aortic expansion (>5 mm/yr). RESULTS: On initial CT, a distal re-entry tear was identified in 9 patients. Two patients failed to achieve proximal tear exclusion by the surgery. Serial follow-up CT evaluations (median, 24.6 months; range, 6.0 to 67.2 months) revealed that 14 patients showed rapid expansion of the descending aorta or aortic aneurysm formation. A multivariate analysis revealed that the residual intimal tear (odds ratio [OR], 4.31; 95% confidence interval [CI], 1.02 to 19.31) and the patent false lumen in the early postoperative setting (OR, 4.64; 95% CI, 0.99 to 43.61) were predictive of the composite endpoint. CONCLUSION: The presence of a residual intimal tear following surgery for acute type I AD adversely influenced the expansion of the descending aorta.

Primary Ewing's Sarcoma of the Lung.

Most cases of Ewing's sarcoma are reported in the bone, and extraosseous Ewing's sarcoma is an extremely rare disease. Here, we report a rare case of primary pulmonary Ewing's sarcoma in a patient with hemoptysis. The patient underwent right upper lung lobe lobectomy with adjuvant chemotherapy and radiation therapy and has been free of recurrent disease for 4 years.

Neuronal autophagy and neurodevelopmental disorders.

Neurodevelopmental disorders include a wide range of diseases such as autism spectrum disorders and mental retardation. Mutations in several genes that regulate neural development and synapse function have been identified in neurodevelopmental disorders. Interestingly, some affected genes and pathways in these diseases are associated with the autophagy pathway. Autophagy is a complex, bulky degradative process that involves the sequestration of cellular proteins, RNA, lipids, and cellular organelles into lysosomes. Despite recent progress in elucidating the genetics and molecular pathogenesis of these disorders, little is known about the pathogenic mechanisms and autophagy-related pathways involved in common neurodevelopmental disorders. Therefore, in this review, we focus on the current understanding of neuronal autophagy as well as recent findings on genetics and the roles of autophagy pathway in common neurodevelopmental disorders.

Aortic root conservative repair of acute type A aortic dissection involving the aortic root: fate of the aortic root and aortic valve function.

OBJECTIVES: Despite many studies about aortic valve function and aortic root geometry after conservative aortic root repair of acute type A aortic dissection, the results are not always consistent or conclusive. This study aims to evaluate aortic root diameter and aortic valve function after surgery for acute type A aortic dissection involving the aortic root. METHODS: A retrospective review was performed of 196 consecutive patients (age, 56.9 ± 11.4 years; 96 men) who underwent conservative aortic root repair including sinotubular junction resuspension for the management of acute type A aortic dissection involving the aortic root. RESULTS: The 30-day mortality rate was 5.1% (n = 10). During a median follow-up period of 45.3 ± 36.4 months, there were 28 deaths and 11 cases of aortic reoperation (proximal reoperation in 1 and distal reoperation in 10). Of the 6-month survivors (n = 177, 90.3%), echocardiography and computed tomography were performed in the late period (>6 months) on 115 (65.0%) and 138 (78.0%), respectively. Significant aortic regurgitation (greater than grade 2+) or root dilatation (>45 mm) was observed in 5 and 19 patients, respectively. Freedom from aortic regurgitation (greater than grade 2+) or root dilatation (>45 mm) at 5 years was 84.6% ± 3.9%. On the Cox regression analysis, the maximal aortic root diameter at initial presentation was the only significant predictor of aortic regurgitation and aortic root dilatation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19; P = .014). CONCLUSIONS: Conservative aortic root repair of acute type A aortic dissection demonstrates acceptable long-term clinical outcomes. However, more aggressive approaches should be considered for patients who have aortic root dilatation because of the risk of developing a root aneurysm after surgery.