[Racemose Hemangioma of the Bronchial Artery with Pulmonary Artery Fistula].

A 55-year-old woman was suspected of having hilar lymph node enlargement on a routine examination of the chest computed tomography( CT) scan at our hospital. On further examination, thoracic contrast CT and bronchial arteriography showed prominent dilation and meandering of the right bronchial artery with an aneurysm which formed a fistula to the pulmonary artery A7 at its distal end. Diagnosed as racemose hemangioma of bronchial artery with pulmonary artery fistula, we performed a surgical resection by open thoracotomy on the second day following bronchial artery embolization( BAE). No recurrence was observed in the five years of follow-up period after surgery. Therefore, surgical resection for asymptomatic racemose hemangioma of bronchial artery with bronchial artery-pulmonary artery fistula can be considered an effective method for the long-term prevention of bleeding.

Intrapulmonary lymph nodes masquerading as pleural metastasis.

Intrapulmonary lymph nodes (IPLNs) are a frequent finding of computed tomography for lung cancer and can grow without malignant findings. Linear densities extending from the nodules are a characteristic of IPLNs.

Curative thoraco-systemic therapy plus local treatment to the brain for extensive disease-small-cell lung cancer with metastasis only to the brain.

We reviewed 11 cases of extensive disease (ED)-SCLC and metastasis only to the brain treated during 2011-14. All patients underwent definitive therapy similar to that for limited disease (LD), combined with local treatment for BM. We compared the survival outcomes of these patients to those of patients with LD (n = 29) or other ED (n = 38) during the same period. Three patients had progression of BM at completion of chemotherapy. Ten patients received whole-brain radiotherapy (4 prophylactic, 6 therapeutic), and remaining one elderly patient underwent stereotactic radiosurgery. Finally, 8 and 3 patients achieved a CR or PR of BM, respectively. Five remained free of progression for 21.1-73.2 months. The progression-free and overall survival outcomes of ED-SCLC with brain only metastases were comparable to those of LD and superior to those of other ED. In conclusion, ED-SCLC with metastasis limited to the brain could be treated with curative intent.

[Thoracic Endovascular Aortic Repair for Traumatic Aortic Injury with Internal Iliac Approach;Report of a Case].

A 40-year-old female was injured in a car accident while driving. Computed tomography confirmed a dissection localized to the distal aortic arch and hematoma around the area. Severe liver damage with surrounding extravasation was also confirmed. Furthermore, multiple rib fractures and lumbar spine fracture were apparent. Thoracic endovascular aortic repair( TEVAR) was performed after transcatheter arterial embolization to treat the liver injury. As both the iliac and femoral arteries were narrow, the internal iliac artery was transected peripherally and used as an access route. This method does not require complex procedures such as artificial vascular anastomosis for vascular repair in the event of injury. Therefore, it may be considered as an option when access from the femoral artery is difficult.

[Surgical Repair for Blunt Cardiac Rupture].

Blunt cardiac injury is a life-threatening condition. We report 3 successful cases in which we performed surgery for blunt cardiac injury. Three individuals were injured, 2 in traffic accidents and the other being caught between a crane and a steel frame. Echocardiograms and computed tomography scans revealed pooling of bloody pericardial fluid in all 3 patients, who underwent emergency surgery. Two patients needed sutures to control persistent bleeding. Although a heart-lung machine was prepared at the start of surgery in all 3 cases, we did not need to use it for any patient. Thus, prior to performing such surgery, it is necessary to ascertain its need.

[Pulmonary Benign Metastasizing Leiomyoma Resected Six Times during Twenty Years;Report of a Case].

Benign metastasizing leiomyoma (BML) is a rare condition in which a benign uterine leiomyoma causes metastasis, mainly to the lungs. The patient was a 72-year-old woman who had undergone hysterectomy for an uterine leiomyoma at 37 years of age. Between the ages of 52 and 68 years, she had undergone 5 metastatectomies for 10 BMLs. At the current presentation, 2 nodules located in the right upper lobe of the lung were resected. The histological diagnosis was BML, and immunohistochemical staining demonstrated that the tumor cells were positive for estrogen and progesterone receptors. Two years after surgery, the patient is alive without recurrence or respiratory symptoms. Multiple resections can be a treatment option for BML.

Outcome prediction of pulmonary metastasectomy can be evaluated using metastatic lesion in osteosarcoma patients.

BACKGROUND: We investigated whether molecular prognostic factors should be evaluated in specimens of the primary or the metastatic lesion and if the prognosis after initial pulmonary metastasectomy can be predicted based on evaluation of metastatic lesion specimens in osteosarcoma patients. METHODS: This retrospective study included 29 osteosarcoma patients with pulmonary metastases (19 males, 10 females; age 21 ± 10 years). Molecular prognostic factors were the levels of vascular endothelial growth factor type A (VEGF-A), VEGF type C (VEGF-C), and Ki67. Primary and pulmonary metastatic lesions could be compared in 18 patients regarding the values of marker expressions and the prognosis after initial pulmonary resection. Finally, the prognosis of all 29 cases was compared according to the molecular markers of the metastatic lesions. RESULTS: Evaluation of the metastatic lesions reflected the prognosis after pulmonary metastasectomy more than that of the primary lesions. In the metastatic lesions, positive expression of VEGF-A (n = 15), VEGF-C (n = 2), and Ki67 (n = 15) was associated with a significantly poorer prognosis (p = 0.0013, 0.0001, and 0.037, respectively). No patients with positive expression of both VEGF-A and Ki67 (n = 7) survived more than 5 years after the initial pulmonary resection. All patients who had negative reactions to both VEGF-A and Ki67 (n = 6) were alive at the end of the study. CONCLUSIONS: Molecular prognostic factors should be investigated in specimens of the metastatic lesion. Combined evaluation of VEGF-A and Ki67 and of VEGF-C using pulmonary metastatic lesion specimens in osteosarcoma patients effectively reflects survival after pulmonary metastasectomy.

Rapidly growing intrathoracic extraskeletal Ewing's sarcoma.

There are few reported cases of intrathoracic Ewing's sarcoma, a very rare malignant neoplasm. We report a surgical case of extraskeletal Ewing's sarcoma that had been followed-up as a stable sized tumour for many years, which then grew rapidly within a year. A 27-year old female patient with a rapidly growing abnormal shadow on chest roentgenogram was admitted to our department. She had undergone periodic examinations including chest computed tomography (CT) scans for 6 years since a small nodule in her chest had been pointed out by chest roentgenogram. The initial CT demonstrated a solitary nodule with a diameter of 20 mm on the parietal pleura that covered the V rib of the posterior chest wall. For 5 years the tumour's size did not change noticeably but it suddenly grew to about 90 mm diameter in a year. The tumour volume doubling time was calculated to be 17 days.

Electrothermal bipolar vessel sealing device LigaSureV for pulmonary artery ligation--burst pressure and clinical experiences in complete video-assisted thoracoscopic major lung resection for lung cancer.

Intraoperative bleeding is one of the main severe complications in complete video-assisted thoracoscopic surgery (c-VATS). We investigated whether one sealing device, the LigaSureV (LSV) vessel sealing system (Valleylab, Tyco Healthcare, Boulder, CO, USA) was experimentally and clinically safe and effective for c-VATS. The burst pressures (BP) of each pulmonary artery (PA) in resected lungs were measured and were compared between a thin PA group (<5 mm) and a thick PA group (> or =5 mm). To investigate the influences of the sealing situations to the adequacy of sealing, BPs were measured after dry or wet conditioned PA (soaked with 0.9% saline) were sealed and cut by the LSV. Clinically, a total of 203 PA were divided with the LSV in c-VATS. The BP of the thin PA with small diameters (<5 mm) were higher than the thick PA (607 mmHg vs. 447 mmHg; P<0.05). The sealing effect was higher when the thick PA was sealed in a dry state than in a wet state (447 mmHg vs. 399 mmHg; P<0.05). However, average BP was physiologically high enough to inhibit a burst even for thick PA sealed in a wet state. There was single case of delayed bleeding sealed PA resulted from seal contact with a sucton device. These studies demonstrated the safety and efficacy of the LSV to sealed PA in c-VATS.

Activation of coagulation and fibrinolysis after off-pump coronary artery bypass grafting with or without endotracheal general anesthesia.

OBJECTIVE: : In this study, we measured the activity of coagulation and fibrinolysis and clarified the presence of certain differences between off-pump coronary artery bypass grafting (OPCAB) cases and awake off-pump coronary artery bypass grafting (AOCAB) cases to evaluate whether AOCAB is actually safe from the viewpoint of coagulability. METHODS: : 8 underwent OPCAB and 6 underwent AOCAB. The following factors inducing coagulation and fibrinolysis were measured for upto 5 days after the operation: platelet counts, prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degeneration products, d-dimer, thrombin-antithrombin III complex (TAT), α2-plasmin inhibitor-plasmin complex, prothrombin fragment 1, 2 (F1+2), thrombomodulin, ß-thromboglobulin (ß-TG), and platelet factor-4. RESULTS: : At 5 days after the operation, fibrin degeneration products, d-dimer, α2-plasmin inhibitor-plasmin complex, and F1+2 levels of the OPCAB group were significantly higher compared with their baseline values and those of the AOCAB group. At 5 days after the operation, thrombin-antithrombin III complex levels of the OPCAB group were significantly higher than those of the AOCAB group. Fibrinogen levels of the OPCAB group were significantly higher than their baseline values at 3 days after the operation (POD3) and 5 days after the operation (POD5). CONCLUSIONS: : In this study, the hypercoagulable state at POD5 was suggested in the patients in the OPCAB group, but not in those in the AOCAB group. Further study is necessary to confirm these results, and future studies would evaluate the potential benefit of AOCAB procedure from the viewpoint of perioperative coagulability.

Management of tracheobronchial ulceration induced by high-dose brachytherapy.

The most severe complication of high-dose endobronchial brachytherapy is fatal hemoptysis. Intractable tracheobronchial ulceration due to high-dose endobronchial brachytherapy often develops into tracheobronchial necrosis and fatal hemoptysis. Our experience demonstrated that when bleeding from tracheobronchial ulcer, after high-dose endobronchial brachytherapy occurs, blocking the blood supply to the tracheobronchial ulcer alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis. This is the first report that describes an effective management for preventing fatal hemoptysis.

A case of intrathoracic giant malignant peripheral nerve sheath tumor in neurofibromatosis type I (von Recklinghausen's disease).

The patient was a 32-year-old woman with neurofibromatosis I (von Recklinghausen's disease), with chief complaints of shortness of breath and back pain. CT and MRI revealed a giant mass occupying the right thoracic cavity almost completely. The mass compressed the mediastinal structure to the left and the liver downwards. She underwent surgery to alleviate respiratory and circulatory disorders caused by compression of the right lung and inferior vena cava due to the giant tumor. Intraoperatively, the tumor was found to have originated from the 5th intercostal nerve. The resected tumor was 20x17x15 cm in size and 2,300 g in weight. It was histologically diagnosed as a malignant peripheral nerve sheath tumor. Her postoperative course was uneventful. All indicators of respiratory function improved, and edema of the lower half of the body disappeared, accompanied by disappearance of shortness of breath. She was discharged 21 days after surgery. Seven months after surgery, however, a recurrent tumor was found in the right thoracic cavity. She died of rapid growth of recurrent tumor 3 months thereafter. This tumor often complicates neurofibromatosis I and has a high frequency of local recurrence and distant metastasis, resulting in poor prognosis. Neither an optimal extent of resection needed for complete resection of this tumor nor an optimal regimen of chemotherapy, radiotherapy, or other therapy for the tumor has yet been established. It is desirable to establish them in the near future.

A 90-year-old woman with trachea-invading thyroid cancer requiring four-ring resection of cervical trachea because of airway stenosis.

The patient was a 90-year-old woman with chief complaints of hemoptysis and wheezing. Cervical computed tomography (CT) scans revealed a mass (2.5x2.0 cm) in the right lobe of the thyroid. The mass was exposed into the tracheal lumen, causing marked stenosis of the airway. When examined by bronchoscopy, the maximal degree of airway stenosis was about 75% of the tracheal cross section. During surgery, a resection of the right lobe of the thyroid was combined with a resection of the second to fifth cartilage ring of the cervical trachea for the purpose of complete resection of the thyroid cancer. During the same operation, the trachea was reconstructed by end-to-end anastomosis. For 1 week after surgery, a Mini-Trach II tube was left inserted to aspirate sputum, and the neck was kept bent forward (in the position of flexion). When sleeve resection of the trachea and subsequent end-to-end anastomosis are being performed, it is essential to manipulate the trachea in a protective manner, to preserve the nourishing vessels, to perform operative manipulation aseptically, to appropriately move the trachea, and to ensure reliable suturing with the goal of minimizing the incidence of complications such as anastomotic failure and stenosis of the anastomosed area. Although the patient was in advanced old age, her postoperative course was uneventful.

Successful surgical treatment of chronic inferior vena caval thrombosis following blunt trauma.

Posttraumatic inferior vena cava (IVC) thrombosis is extremely rare. We report a case of surgical treatment for chronic inferior vena caval thrombosis 4 years after blunt trauma. A 22-year-old man was referred to our hospital for investigation of an inferior vena caval thrombosis. He had a history of blunt abdominal trauma at age 18 while dismantling a medium truck and had undergone pancreaticojejunostomy for a pancreatic laceration. Computed tomography (CT) scans revealed an inferior vena caval thrombosis extending into the right atrium. Lung perfusion scintigraphy was unremarkable. We performed thrombectomy through a median sternotomy under deep hypothermic circulatory arrest, which gave adequate visualization in a bloodless field. A fiberscope was used intraoperatively for detailed IVC inspection. Postoperative recovery was uneventful, and he was discharged on the 14th postoperative day. Postoperative CT and echocardiography showed no recurrence of the thrombosis.

A case of cuff stenosis following tracheostomy responding well to T-tube stent insertion: with special reference to methods of dilating the stenosed site.

A 74-year-old man, receiving home oxygen therapy (HOT), required tracheal intubation and artificial ventilation because of methicillin-resistant staphylococcus aureus (MRSA)-induced pneumonia. Tracheostomy was additionally performed. One month later, he had recovered from pneumonia and the tracheostomy tube was withdrawn, allowing the patient to be discharged. One month after discharge, the patient began to complain of wheezing and difficulty in breathing and was thus admitted again to the hospital. Emergency bronchoscopy revealed cuff stenosis. A bronchofiberscope, 4.8 mm in outer diameter (o.d.), was unable to pass through the stenosed site. After the airway was secured by passing a Mini-Trach II tube (4.0 mm in inner diameter (i.d.) and 5.4 mm o.d.) through the stenosed site via the previous tracheostomy stoma, we changed the inserted tracheal tube every other day, replacing it each time with a tube of progressively larger i.d. and o.d. We went from 5.0 mm i.d. (6.9 mm o.d.) to 6.0 mm i.d. (8.2 mm o.d.), 7.0 mm i.d. (9.6 mm o.d.) and finally to 8.0 mm i.d. (10.9 mm o.d.). In this way, the stenosed site was gradually dilated. Finally, a silicon T-tube with 9.0 mm i.d. (11.0 mm o.d.) was inserted via the tracheostomy hole into the trachea and left there. At present, 2 years after the procedure, the patient is continuing HOT and is being followed at an outpatient internal medicine clinic. Cuff stenosis affects the trachea concentric-circumferentially and often relapses even after laser therapy. For these reasons, stent insertion is usually considered as necessary when dealing with cuff stenosis. Our technique of tracheal dilation is safe and simple, and does not require any special device or tool other than tracheal tubes. We report that silicon T-tube stents are optimal for treatment in cases of cuff stenosis.

Postoperative bronchial stump fistula responding well to occlusion with metallic coils and fibrin glue via a tracheostomy: a case report.

An 80-year-old man underwent middle and lower lobectomy of the right lung to treat squamous cell carcinoma (SCC) (4 cm in diameter) originating from the right B4 bronchus. On the 4th postoperative day, a massive air leak from the thoracic drain was noted. At that time, a diagnosis of bronchial stump fistula was made on the basis of the bronchoscopic findings. Continuous thoracic drainage, aspiration of sputum via a tracheostomy and intravenous administration of antibiotics were performed immediately after the diagnosis. However, the patient's condition was complicated by aspiration pneumonia. On the 11th postoperative day, bronchoscopic procedure to close the bronchial fistula was performed via the tracheostomy. During this procedure, metallic coils were first inserted into the fistula to serve as the core for occlusion. Then, instead of directly infusing fibrin glue, several small beans-sized pieces of Surgicell cotton (Johnson & Johnson Co., Cincinnati, OH) soaked in fluid A (concentrated fibrinogen) and the same number of Surgicell cotton pieces soaked in fluid B (thrombin) were alternately inserted into the fistula, to allow closure of the bronchial fistula. After this procedure, the embolus created remained in place without being expectorated, and the aspiration pneumonia entered remission, allowing the patient to be discharged from the hospital on the 24th postoperative day. At preset, 14 months after surgery, the patient is in good condition. This technique allows simple and reliable closure of a fistula if a tracheostomy is available. It should be selected as a therapy of first choice when dealing with patients with a postoperative bronchial stump fistula in poor general condition. Patients undergoing right pneumonectomy or middle and lower lobectomy of the right lung should be considered as belonging to a high risk group for bronchial fistula and as requiring preventable measures (e.g., covering the stump with an intercostal muscle flap).