Purpose: Since its introduction more than a decade ago, thoracic endovascular aortic repair (TEVAR) has shown promising results for patients with various thoracic aortic diseases. The aim of the current review is to assess the current literature to evaluate the safety and efficacy of TEVAR. Methods: A thorough search of the existing literature on TEVAR was conducted on electronic databases, including Medline, Pubmed, EMBASE and Database of Abstracts of Review of Effectiveness. The most recent results were categorized according to the indications of performing TEVAR. Results: A number of case-series studies and reviews have shown reduced early morbidity and mortality rates in a range of thoracic aortic diseases for TEVAR in comparison to open surgical repair. However, there is a lack of robust clinical data to suggest any improvement in long-term overall survival. Conclusion: Despite numerous encouraging results from a large number of publications in recent years, there remains a lack of level 1 evidence to support an improvement of long-term overall survival for patients who underwent TEVAR when compared with traditional treatment modalities. There appears to be an urgent need to conduct well-designed randomized-controlled trials in this rapidly expanding intervention.
Background: We reviewed resection of pulmonary metastases preformed by the Department of Thoracic Surgery at Kyoto University Hospital to confirm the clinical significance of this surgery in patients with colorectal carcinoma and a history of hepatic metastasis. Methods: From 1992 to 2006, 19 patients with colorectal carcinoma and a history of hepatic metastasis underwent a pulmonary metastasectomy . Surgical outcomes of these patients were investigated in terms of various perioperative variables. Results: Sixteen of 19 patients showed metachronous presentation of hepatic and pulmonary metastases, while 3 patients showed synchronous presentation. Overall survival rate after the pulmonary resection was 93%, at 1 year; 75%, at 3 years and 60% at 5 years. Three years after the pulmonary resection, none of the patients with synchronous hepatic and pulmonary metastases survived, while patients with metachronous metastases had an overall survival rate of more than 80%. Interestingly enough, the overall survival curve of the patients with colorectal carcinoma and a history of hepatic metastasis, who underwent a pulmonary metastasectomy was almost the same as that of patients who did not have the surgery, during the same period. Conclusion: Aggressive resection of pulmonary metastases in a select group of colorectal cancer patients with a history of liver metastases might result in prolonged survival.
Background: Human T-cell lymphotropic virus type 1 (HTLV-I) causes not only adult T-cell leukemia (ATL) but also HTLV-I associated T-cell bronchioloalveolitis, which is often chronic and subclinical. We have experienced eight HTVL-I carriers with bronchioloalveolar carcinoma, which is known to arise from bronchioloalveolar pneumocytes. This case–control study clarified the risk of bronchioloalveolar carcinoma in HTLV-I carriers. Materials and Methods: During the past four years, 212 lung cancer patients were examined for serum anti-HTLV-I antibody. They underwent surgical treatment for lung cancer at Kumamoto University Hospital. Of these, 8 (4%) were HTLV-I carriers. As controls for this case-control study, we selected 24 HTLV-I negative-lung cancer patients (1:3 case-control ratio) matched for sex, age, and smoking status. The distributions of histological types of lung cancer were compared between the case (HTLV-I positive) and control (HTLV-I negative) groups. Results: Histological types of the 8 HTLV-I carriers were bronchioloalveolar carcinoma in 6 patients and adenocarcinoma with bronchioloalveolar carcinoma component in 2. The prevalence of bronchioloalveolar carcinoma in HTLV-I carriers, 6 of 8 (75%), was significantly higher than the 6 of 24 (25%) in HTLV-I negative patients (p = 0.02). The prevalence of bronchioloalveolar carcinoma or adenocarcinoma with bronchioloalveolar carcinoma component in HTLV-I carriers, 8 of 8 (100%), was also significantly higher than the 13 of 24 (54%) in HTLV-I negative patients (p = 0.02). Conclusion: HTLV-I might be one risk of bronchioloalveolar carcinoma, probably because of inflammatory and/or immunologic responses involving bronchioloalveolar pneumocytes.
Purpose: We report our experience with completion pneumonectomy (CP). Methods: We report on operative procedure and morbidity, mortality, and survival rates. Results: CP was performed for malignancy in 12 patients and postoperative complications after the first operation in 4 patients. Intrapericardial dissection of vessels was performed in 14 patients (87.5%). Partial vertebrectomy from the second to the fifth vertebrae was performed in 1 patient. Carinal resection was performed in 2 patients. Morbidity including bronchopleural fistula, pulmonary insufficiency, pyothorax, and pulmonary infarction developed in 6 of the 16 patients (37.5%). Mortality rate was 18.8%. The actuarial 1-, 3-, and 5-year overall survival after CP for all malignancy was 80.8%, 49.0%, and 49.0% respectively. Conclusions: The morbidity and mortality rates are high in CP. Combined resection, especially carinal resection, appears to be contraindicated in CP. CP is one of the treatments of choice, even for malignancy, if complete resection is possible because of the good long-term survival.
Objective: Tracheostomy is one of the most frequent interventions for ICU patients. The current trend in performing a tracheostomy is a percutaneous approach because of its popularity and significant advantages. In this study, certain indications of surgical tracheostomy (ST) are suggested and furthermore, ST is compared with percutaneous tracheostomy (PT). Patient and Methods: We performed a U-shaped ST in 121 patients and PT in 85 patients between March 2003 and December 2006. All of the STs were opened U-shaped in the operating room. In this technique; instead of removing the tracheal ring, it was used to create a flap. The tracheal flap was hung with a suture from middle of the 2nd or the 3rd cartilage rings, as a guide. Also, the PT procedure “Griggs dilatation technique” was performed in the ICU. Results: PT and ST had similar complication rates: 4.1% for ST [bleeding in 2 patients, stenosis in 2, and stomal infection in 1] versus 3.6% for PT [bleeding in 2 patients, and pneomothorax in 1] (p = 0.08). No significant difference was found regarding mean operation time between ST [12 min (9–18)] and PT [8 min (6–16)] (p = 0.09) Conclusions: Staff utilization and cost seem like the major advantages of PT. However, our surgical technique has similar complication rates with PT and moreover, using ST still remains favorable for select patients with thyroid hyperplasia, short neck, tracheaomalacia, obesity, neck operation history and for children.
Purpose: The aim of this study was to quantify the amount of brain damage suffered by patients who underwent off-pump coronary artery bypass grafting (OPCAB) in which S-100β protein and neuron-specific enolase were used. Methods: Thirty-four patients undergoing scheduled OPCAB were enrolled in the study. The patients were divided into two groups according to the results of their magnetic resonance angiography (MRA) and cervical ultrasonography: 13 patients had cervical or intracranial arterial stenosis (Group A), and 21 patients did not (Group B). Blood samples were collected from the arterial catheters immediately before surgery, upon arrival to the intensive care unit, and 6 and 24 hours after surgery. Results: In blood samples collected from patients upon arrival to the intensive care unit, the maximum concentration of serum s-100β protein in Group A was significantly higher than that of Group B (p = 0.029). Though patients in Group A tended to have higher maximum neuron-specific enolase (NSE) concentrations, there were no significant differences in NSE concentrations at any point between the two groups. Conclusions: Our findings show a correlation between the stenosis detected by MRA or cervical ultrasonography and brain damage after OPCAB.
Objectives: The present study was undertaken to identify risk factors for permanent neurological dysfunction (PND) and in-hospital mortality after total aortic arch replacement (TAR) with separate arch vessel grafting using selective cerebral perfusion (SCP) and hypothermic circulatory arrest. Methods: Between 1998 and 2008, we preformed a TAR on 143 consecutive patients in two centers by identical methods. Of these, 19 (13.3%) were emergency operations, and 46 (32.2%) were open stent-graft placements. Statistical analysis was performed to determine risk factors for PND and mortality, and furthermore, the survival rate was analyzed. Results: The in-hospital mortality rate was 4.9%, with chronic renal failure (p = 0.0013, odds ratio 10.0) as a significant risk factor. Nine patients (6.3%) had PND, with significant risk factors identified as (1) the presence of an old cerebral or silent lacunar infarction on preoperative imaging methods (p = 0.0458, odds ratio 8.0) and (2) duration of SCP (p = 0.0026, odds ratio 1.036). Long-term survival was the same in patients with or without PND. Conclusion: The enhanced vulnerability of the brain in patients with a pre-existing old cerebral infarction or silent lacunar infarction is reflected by a high incidence of PND. Chronic renal failure had an impact on in-hospital mortality.
We describe herein a case of a 68-year-old woman with primary lung cancer who had undergone induction chemoradiotherapy and then a right pneumonectomy for non-small cell cancer (adenocarcinoma). Twenty-one months later, the cancer had metastasized to the brain, which was treated with 2-knife radiosurgery. She had been well for up to 32 months; however, the chest radiography and chest computed tomography (CT) demonstrated a nodule in the left upper lobe of the lung that was gradually growing. We preformed a partial resection of the left upper lobe by video-assisted thoracic surgery (VATS) under percutaneous cardiopulmonary support (PCPS), considering the oxygenation requirement of the patient. PCPS was applied via venoarterial (V-A) bypass, and the hemodynamic status of the patient was mostly stable. The postoperative course was uneventful, and the patient has no evidence of metastatic lung cancer, 10 months postoperatively, indicating that the minimally invasive VATS under PCPS was successful and safe. Although few reports have been described and some key questions remain unanswered, the method appears to be promising.
We report a relatively rare surgical treatment for two cases of inflammatory pseudotumors of the lung. In case 1, a 52-year-old male with a history of left chest pain was admitted to our hospital for an abnormal nodule with an irregular margin that was detected in the left upper lung field. The nodule, measuring 15 mm in diameter, was larger than the one observed six months earlier, which had been removed by a thoracoscopic resection. In case 2, a 64-year-old female with a history of chronic cough and hemoptysis was admitted to our hospital, and an abnormal nodule with pleural indentation was detected in the lower left lung field. The nodule, measuring 8 mm in diameter, was also removed by a thoracoscopic resection. In both cases, the histologic examination enabled us to diagnose the lesion as an inflammatory pseudotumor. In general, it is very difficult to differentiate inflammatory pseudotumors from malignant tumors of the lung. The best treatment for inflammatory pseudotumors is usually early and complete surgical resection, since it can lead to improved survival. Therefore, we consider thoracoscopy-aided surgery to be less invasive and more useful than other surgical methods in the diagnosis and treatment of inflammatory pseudotumor of the lung.
Central airway obstruction (CAO) and superior vena cava (SVC) syndrome are potentially life-threatening complications in locally advanced lung cancer. Therapeutic rigid bronchoscopy has become an critical component in the treatment of the lung cancer patients with CAO who are not surgical candidates. However, the technique may pose significant risks in patients with coexisting SVC syndrome, especially, and even more so perhaps in patients over the age of eighty. In this case report, we address the potential risks and known benefits of therapeutic bronchoscopic intervention in an 85-year-old man with small cell lung cancer who presented with acute dyspnea secondary to advanced SVC syndrome and CAO involving the lower trachea and right main bronchus. Emergent therapeutic rigid bronchoscopy resulted in a marked improvement, in dyspnea, atelectasis, and postobstructive pneumonia, allowing rapid administration of systemic chemotherapy.
Purpose: In pathologic IB (pIB) non-small cell lung cancer, especially in adenocarcinoma, adjuvant chemotherapy with uracil-tegafur is widely recognized as being effective. The aim of this study was to determine the prognostic factors of pIB disease. Patients and Methods: Sixty patients who were diagnosed with pIB disease between 2004 and 2007 were retrospectively analyzed. Results: Of 60 patients, 22 (36.7%) opted for surgery plus adjuvant chemotherapy with uracil-tegafur, whereas 38 (63.3%) opted for surgery only. The oral administration dose of uracil-tegafur was 400 mg/body. Compliance of adjuvant chemotherapy with uracil-tegafur was 65.5% in 12 months, 57.3% in 24 months. Adjuvant chemotherapy was interrupted in 11 patients because of the recurrence of disease in 3 patients and adverse reaction in 8 patients. Anorexia was the most common adverse reaction. The larger tumor diameter (5cm<) and p2 pleural invasion were the worse prognostic factors in disease free survival in a univariate analysis and a multivariate analysis (hazard ratio = 0.26 and 0.25; p = 0.028 and 0.032, respectively). Conclusion: The prognosis of the patients with pleural invasion and a tumor diameter >5cm was poor, and these, partly support the forthcoming classification.
A 70-year-old man with T1N3M1 stage IV squamous cell carcinoma in the right upper lobe of the lung developed chylothorax and chylopericardium as rare simultaneous complications. Intravenous hyperalimentation, repeated pleurodesis, and ligation of the thoracic duct were all ineffective. A pleuroperitoneal shunt was inserted into the right pleural cavity from the fifth intercostal space, and a peritoneal catheter was placed in the abdominal cavity. Chylothorax was markedly improved, and the quality of life of the patient increased. This case indicates that a pleuroperitoneal shunt can be used for lung cancer-related chylothorax, as well as for malignant pleural effusion.
A 61-year-old asymptomatic man underwent a left pneumonectomy for Stage IIIA lung cancer. At thoracotomy, the pericardium was found to be completely absent; however, we did not close the defect. Although the heart was rotated toward the left pleural cavity in the postoperative chest computed tomography (CT), the postoperative course was uneventful, and the patient has remained asymptomatic for 7 months, since the resection. We reviewed the preoperative chest CT, which showed the heart extending unusually to the left, but the pericardial defect was not evident. Complete pericardial defects usually do not endanger the lives of patients, and if the patient is asymptomatic, surgical repair of the defect may be unnecessary even during a left pneumonectomy.
Alveolar adenoma is a rare pulmonary neoplasm. This report describes a case of alveolar adenoma of the lung in a 61-year-old woman. A chest X-ray demonstrated a solitary round pulmonary nodule. After six years of observation, this lesion had increased in size. Thoracoscopic left upper segmentectomy was performed on account of a possible low-grade malignant tumor. Histologically, the neoplastic epithelial cells, which had the appearance of proliferative type II pneumocytes, revealed no evidence of malignancy. These findings indicated that the tumor is alveolar adenoma of the lung. The course of disease remains uneventful, one year after the resection.
The patient was a 76-year-old man who had a prior history of recurrent pneumonia and severe, chronic sinusitis. Computed tomography showed a thymoma, and laboratory results revealed hypogammaglobulinemia. Therefore, Good’s Syndrome (GS, rare adult-onset immunodeficiency with thymoma) was diagnosed. To treat his sinusitis, we started the patient on long-term clarithromycin therapy, preoperatively. A thymothymectomy was performed, but the immunological disorder was not resolved. Although standard gamma globulin replacement was not given, his sinusitis symptoms were ameliorated, and he has not had pneumonia since the operation. Long-term macrolide therapy probably plays some role in managing sino-pulmonary infections associated with GS.
A hernia of Morgagni (also called hernia of Morgagni-Larrey) is a congenital herniation of abdominal contents into the thoracic cavity through a retrosternal diaphragmatic defect. The Morgagni hernia can create uncertainty in its diagnosis and difficulty for subsequent treatment. If after clinical examination and x-ray we suspect the hernia, computed tomography imaging should be the desired imaging method to confirm the diagnosis. Surgery is the only definitive treatment. When a patient presents signs and symptoms of incarceration or strangulation, emergency surgery is required. We report the first life-threatening case of an association between a hernia of Morgagni and a mediastinal lipoma. We present an adult patient with mediastinal lipoma and a right incarcerated hernia of Morgagni with engagement of the stomach, the duodenum and the transverse colon, successfully treated without complications. To our knowledge, this is the first report of an association between those two rare entities in an acute setting. We discuss the differential diagnosis and physiopathology of the condition, referring to published reports.
We report the successful treatment of a 77-year-old man after a difficult diagnosis of mitral valve regurgitation resulting from complete rupture of the anterior papillary muscle. The patient with cardiogenic shock was an emergency admission. An electrocardiogram showed acute lateral wall myocardial infarction. He had complications of leukocytosis and a high-grade fever. Transesophageal echocardiography seemed to show the appearance of a large area of vegetation attached to the anterior mitral valve leaflet and aortic non-coronary cusp, resulting in severe mitral regurgitation. We performed coronary angiography, which showed complete obstruction of the circumflex coronary artery. We determined that the condition was caused by infective endocarditis. Emergency surgery showed the complete rupture of the anterior papillary muscle, but there was no vegetation. The mitral valve was replaced with a bioprosthetic valve and the circumflex coronary artery was bypassed with a saphenous vein graft. Pathological examination revealed mitral valve to be non-mycotic, and the postoperative course was uneventful.
Reoperation in patients with patent coronary artery bypass grafts behind the sternum is associated with a high risk of graft injury that may be life-threatening. We recently performed mitral valve replacement in a patient with patent coronary artery bypass grafts and grade IV mitral regurgitation. Surgery was safely performed with minimal adhesion dissection and modified Port-Access Technique using an aortic balloon.
We describe a new technique for the early surgical repair of a posterior postinfarction ventricular septal perforation (VSP) in two consecutive female patients. The occurrence of a posterior VSP is rare, and its repair is technically difficult because the posteromedial papillary muscle is located adjacent to the intraventricular septum. This modification appears to prevent leaks to the right ventricle through the VPS with a single direct patch and the use of two equine pericardial patches to form a single endocardial pouch. The women were 77 and 62 years old, and the time between the onset of acute MI and surgery was 3 and 6 days. On preoperative catheterization, Qp/Qs was 4.18 and 4.01. Neither operative death nor residual shunting was observed.
Coronary pseudoaneurysm usually occurs after catheter-based intervention as a result of traumatic dissection or perforation of a coronary artery in 4%–5% of cases. Here, we report the successful case of pseudoaneurysm occurring after percutaneous coronary angioplasty (PTCA) against the severely calcified coronary artery treated with off-pump long onlay patch bypass technique using internal thoracic arteries. We report the case of a 59-year-old woman treated with off-pump onlay patch grafting for pseudoaneurysm after coronary angioplasty against the diffusely calcified coronary lesion. The portion of the endoarterectomized left anterior descending coronary artery proximal to the resected aneurysm extending 5cm distally was successfully reconstructed with long onlay patch using the internal thoracic arterial graft.