The pedicled colon segment is widely accepted as a substitute to the gastric tube in esophageal reconstruction of cases where the stomach is not available. The usefulness of reconstruction with a pedicled jejunum has also been reported in recent years. In order to make a long jejunal graft, at least the second and third jejunal vessels have to be severed. However, this leads to a decrease of circulation in the pedicled jejunum. This poor circulation was primarily responsible for the high rates of gangrene and mortality (22.2% and 46.5%, respectively) in the beginnings of jejunal reconstruction. Advances in microsurgery have now enabled surgeons to overcome these disadvantages, as a result, both the rates of gangrene and mortality have decreased to almost zero since the addition of microvascular anastomosis with the jejunal vessels and the internal thoracic vessels. At present, the reconstruction using a pedicled jejunum is a safe operation that provides such advantages as a low incidence of intrinsic disease, more active transport of food, and a lower rate of regurgitation by peristalsis, compared with the reconstruction using the pedicled colon. The disadvantage of the procedure is the relatively high rate of anastomotic leakage (11.1% to 19.2%). Improvements in the surgical procedures to overcome this disadvantage are, therefore, needed before it can be recommended without any reservations.
Background and Aim: The effects of DNA repair pathway on survival were assessed by measuring the tumoral excision repair cross complementation 1 (ERCC1) expression in patients with resected non-small cell lung carcinoma (NSCLC). We aimed to determine the prognostic and predictive significance of ERCC1 in patients with completely resected NSCLC. Methods: Immunohistochemistry (IHC) was used to assess the expression of ERCC1 in resected lung tumor samples obtained from 98 patients untreated without pre- or post-operative chemotherapy and/or radiotherapy. The median H score was used as a cut-off for ERCC1 IHC. Univariate and multivariate analyses were performed for factors influencing patient survival. Results: The 5-year survival rates of patients for ERCC1 positive expression and ERCC1 negative expression were 76% and 49%, respectively; this difference was statistically significant (p = 0.004). Subsequent multivariate analysis suggested that ERCC1 expression (adjusted hazard ratio for death, 0.38; 95% CI, 0.18 to 0.78; p = 0.008) and pathological stage (2.2; 95% CI, 1.09 to 4.5; p = 0.027) were both independent prognostic factors. Conclusion: The level of ERCC1 expression in tumors a strong predictor of survival in resected NSCLC patients untreated without pre- or post-operative chemotherapy and/or radiotherapy.
Purpose: Pulmonary artery coil embolization (PACE) is increasingly utilized to treat pulmonary arteriovenous malformations (PAVMs), but the long-term outcome of this treatment modality remains unclear. By evaluating the long-term outcome of patients at St. Marianna University Hospital treated with PACE, we wanted to see if PACE could effectively replace the surgical resection of PAVMs. Patients and Methods: We retrospectively evaluated 9 consecutive patients (4 males, 5 females; age range, 16-67 years; mean ± SD, 43.6 ± 18.7 years) who underwent PACE for PAVMs. Selective pulmonary artery angiography using Seldinger’s method was initially performed to identify the feeding arteries. This was followed by embolization using interlocking detachable coils and microcoils. Results: The procedure resulted in no severe complications. All treated patients were free from PAVM symptoms. A recurrence did not occur after PACE in 8 of 9 (88%) patients for 31 to 173 months (86 ± 51). Recanalization of the embolized malformation occurred after 3 months in one patient. This patient underwent an additional successful PACE without any further recurrences for 73 months. Conclusions: PACE is an organ-sparing therapy with satisfactory long-term results. It can safely replace the surgical resection of PAVMs.
Background: At Juntendo University Hospital, Japan, two patients with complete resection of bulky N2 non-small cell lung cancer (NSCLC) has survived over the long term. Therefore, we decided to retrospectively study patients who also had a complete resection of the tumor including the “bulky” superior mediastinal node for the purpose of reviewing covariates that might be related to the favorable outcome. Methods: We retrospectively analyzed the relation between covariates and survival after complete lobectomy and mediastinal lymph node resection (from April 1997 to August 2007) in 15 patients with bulky N2 NSCLC, lymph nodes greater than 2 cm in short-axis diameter (bulky nodal disease) measured on preoperative chest computer tomography. Results: Of 15 patients, 5 with bulky N2 single station had survival after the resection. Univariate analysis revealed that the postoperative stage significantly affected overall survival (p = 0.0101). Single-station node involvement in bulky N2 disease was the covariate associated with overall survival (p = 0.0150) and disease free survival (p = 0.0052). Conclusions: In the complete resection of bulky N2 NSCLC in patients with lymph nodes measuring more than 2 cm in short-axis diameter, single-station node involvement suggests a favorable outcome and long-term survival, compared to patients with multi-station involvement.
Introduction: Pleural malignant mesothelioma is an uncommon but extremely invasive tumor which originates from mesothelial cells and usually occurs after prolonged exposure to asbestos. Different types of surgical and oncological therapeutic methods have been used resulting in various outcomes. The aim of this study was to evaluate, clinicopathologically, 40 patients with pleural malignant mesothelioma and the main factors influencing their prognosis. Methods: In this study, 40 patients with a definitive diagnosis, who had been followed up for at least 3 years were studied according to these: epidemiologic factors, stage and pathological types, treatment method and complications, and by using factors that influence patients survival, we evaluated them statistically. Results: The M/F ratio was l3/1 with an average age of 55 years. Chest pain was the most common symptom. In 55% of patients, the lesions were localized in the left site and most were in Buchart stage I or II. The epithelial form was the most common pathological pattern (62.5%). 47.5% of patients only received radiotherapy and chemotherapy. Of patients who underwent decortication and pleurectomy with adjuvant therapy, extrapleural was performed in 20% of patients, and pneumonectomy, in 17.5%; and 15% refused any type of treatment. One patient died from the surgery. The most common surgical complication was wound infection. The average survival was 10.5 months, and the main factors influencing the survival were physiologic status, pathological form of disease, stage of disease and the pattern of pleural involvement. Conclusion: Because of the low survival after multimodality invasive treatments in mesothelioma, aggressive therapeutic methods were recommended in patients with good physiological status and early clinical stage with a good pathology type.
Objectives: Reduction of cognitive function is a possible side effect after the use of cardiopulmonary bypass (CPB) during cardiac surgery. Since it has been proven that piracetam is cerebroprotective in patients undergoing coronary bypass surgery, we investigated the effects of piracetam on the cognitive performance of patients undergoing open heart surgery. Methods: Patients scheduled for elective open heart surgery were randomized to the piracetam or placebo group in a double-blind study. Patients received 12 g of piracetam or placebo at the beginning of the operation. Six neuropsychological subtests from the Syndrom Kurz Test and the Alzheimer’s Disease Assessment Scale were performed preoperatively and on day 3, postoperatively. To assess the overall cognitive function and the degree of cognitive decline across all tests after the surgery, we combined the six test-scores by principal component analysis. Results: A total of 88 patients with a mean age of 67 years were enrolled into the study. The mean duration of CPB was 110 minutes. Preoperative clinical parameters and overall cognitive functions were not significantly different between the groups. The postoperative combined score of the neuropsychological tests showed deterioration of cognitive function in both groups (piracetam: preoperative 0.19 ± 0.97 vs. postoperative -0.97 ± 1.38, p <0.0005 and placebo: preoperative -0.14 ± 0.98 vs. postoperative -1.35 ± 1.23, p <0.0005). Patients taking piracetam did not perform better than those taking placebo, and both groups had the same decline of overall cognitive function (p = 0.955). Conclusion: Piracetam had no cerebroprotective effect in patients undergoing open heart surgery. Unlike the patients who underwent coronary surgery, piracetam did not reduce the early postoperative decline of neuropsychological abilities in heart valve patients.
Purpose: Drug resistance has become a major problem in the treatment of tuberculosis, and pulmonary resection in combination with chemotherapy appears to be an effective measure for the treatment. The purpose of this study was to investigate the results of resection for multidrug-resistant pulmonary tuberculosis (MDR-TB). Patients and Methods: We retrospectively reviewed case files from January 2003 to December 2006 of 13 patients with MDR-TB underwent pulmonary resection. Results: Of 13 patients, 7 (53.9%) were sputum positive for mycobacterium tuberculosis preoperatively, though after surgery, they were sputum negative. Lobectomy was performed in 8 (61.5%) and pneumonectomy, in 5 (38.5%). In the lobectomy group, 2 patients had an additional superior segmentectomy and 1 had a middle lobectomy for other segmental or lobar lesions. Operative mortality was 7.6% (1/13). There were no late surgical deaths. In the early postoperative period, 3 patients had serious complications (postoperative bleeding, prolonged air leak, expansion deficit, bronchopleural fistula and empyema) that were resolved with surgery (morbidity 23.0%). The 12 patients who survived the operation received appropriate chemotherapy and were followed up for 24-37 months. None of the patients relapsed, and the overall cure rate was 92.3% (12/13). Conclusion: Even with high morbidity in the early post-operative period, surgery, in addition to medical therapy, offers higher cure rates than only medical therapy; however, meticulous preoperative evaluation of patients is needed.
Purpose: We evaluated medium-term results of the left-sided maze procedure using cryoablation in patients with valvular heart disease. Methods: We retrospectively evaluated 111 patients with valvular heart disease who underwent the cryosurgical left-sided maze procedure. The mean follow-up period was 36.8 ± 24.9 months, and the mean duration of atrial fibrillation was 5.6 ± 6.0 years. The primary surgical procedure was mitral valve replacement in 42 patients, mitral valve plasty in 28, aortic valve replacement in 25, and combined aortic and mitral replacement or plasty in 16. Results: The 7-year actuarial survival rate was 82.9 ± 11.4% for patients in sinus rhythm and 87.0 ± 7.0% for patients with atrial fibrillation, showing no difference between the two groups (p = 0.236). At final follow-up, 86 out of 111 patients (77.5%) remained free from atrial fibrillation. Sinus rhythm was maintained in 26 of 42 patients (61.9%) in the mitral valve replacement group, 26 of 28 patients (92.9%) in the mitral valve plasty group, 15 of 17 patients (88.2%) in the aortic valve replacement group, and 18 of 24 patients (75.0%) in the combined aortic and mitral replacement or plasty group. The overall actuarial rate of freedom from atrial fibrillation at 5 years after surgery was 70.4 ± 6.0%. Conclusion: The cryosurgical left-sided maze procedure is a safe, simple, and excellent operation for medically refractory atrial fibrillation.
Objective: The aim of this study was to determine the impact of patient-prosthesis mismatch (PPM) after mitral valve replacement (MVR) on the late clinical outcome, evaluated from the referred value and measured mitral valve area in the echocardiograph. Patients and Method: The records of 212 patients who underwent MVR between 1995 and 2008 at Funabashi Municipal Medical Center, Japan were studied retrospectively. Exclusions were patients who had a repeat MVR or concomitant aortic valve surgery. Of 212 patients, 163 underwent the Doppler echocardiographic study more than 1 year after surgery. Primary endpoint was late survival, and secondary endpoint was major adverse cardiac event (MACE). The average follow-up period was 53.1 ± 100.8 months. The effective orifice area index (EOAI) was calculated using the referred effective orifice area (r-EOA) and measured effective orifice area (m-EOA). An EOAI smaller than 1.2 cm2/m2 defined PPM. Results: For r-EOAI, 125 patients (group P) had PPM and 87patients (group N) did not. Between groups, there was a significant difference in the proportion of males (group P vs. N; 59% vs. 23%; P = 0.0001), postoperative NYHA class (1.02 ± 6.2 vs. 9.8 ± 1.6, P = 0.04), late mitral valve area (MVA) (2.50 ± 0.56 vs. 2.78 ± 0.60, P = 0.005), and peak transmitral pressure gradient (MPG) 11.9 ± 6.2 vs 9.8 ± 1.6, P = 0.04). However, there was no difference in late survival (P = 0.55) or incidence of a major cardiac adverse event (MACE) (P = 0.14). For m-EOAI, 17 patients (group P) had PPM and 146 patients (group N) did not. Between groups, there was a difference in the bioprosthetic valve (group P vs. N; 76% vs. 26%, P = 0.006) and mean MPG (5.2 ± 2.3 vs. 3.7 ± 1.8, P = 0.02). However, there was no difference in late survival (P = 0.99) and incidence of MACE (P = 0.86). The r- and m-EOAI were well correlated (correlation coefficient 0.46; 0.33–0.5) Conclusions: The PPM after MVR was not related to the late survival or the incidence of MACE based on both r- and m-EOAI. The patient group of PPM defined by r-EOAI tended to be male and that defined by m-EOAI tended to be bioprosthetic.
Purpose: The aim of this study was to evaluate a new flow analyze device that can intraoperatively measure compliance and resistance of coronary artery bypass grafting (CABG) by the parameter identification method. Methods: Subjects were 95 patients who underwent CABG. Angiography soon after surgery confirmed patency in 90 grafts and graft failure in 5 grafts. Variables of Aortic pressure and the graft flow were entered into this new device that includes a mathematical coronary circulation model to extrapolate other information the data; thus, we can estimate intraoperative flow rate, resistance, and compliance. Flow rate, resistance, and compliance were compared between patent and failed graft groups and among three different type grafts. Results: There were no differences in flow rate, resistance, and compliance among the three grafts types. Between the patent and failed graft groups, there were statistically significant differences in flow rate and resistance, and compliance tended to be lower for the failed graft group. Conclusions: By measuring graft resistance and compliance, this new device is useful for evaluating graft performance during CABG.
We report a case of a 48-year-old man with a history of violent coughing fits and general fatigue underwent urgent surgery for cardiac tamponade, and who was later diagnosed with metastatic intracardiac squamous cell carcinoma of the esophagus. After admittance to Munakata Suikokai General Hospital, Fukuoka, Japan, echocardiography showed extensive pleural and pericardial effusion and a mass, 4 by 2 cm, with a solid echo pattern in the right ventricular cavity. The working diagnosis was primary malignant cardiac tumor of unknown origin with multiple metastases. To prevent sudden death due to obliteration of the outflow tract of the right ventricle, we performed urgent surgery for cardiac tamponade. Histological examination of the resected tumor revealed squamous cell carcinoma. Fiberoptic esophagoscopy showed hypertrophy of the esophageal wall and a submucosal tumor extending throughout the esophagus. Microscopic examination of the esophagus biopsy specimen showed moderately differentiated squamous cell carcinoma, the histology of which was similar to that of the resected tumor and cytology of pericardial effusion. The patient recovered and was able to return home for a few days; however, he was readmitted, and despite maximal supportive therapy, he died one month after the operation.
Malignant melanoma (MM) is the most fatal cutaneous neoplasm. Primary MM of the lung is quite rare, and late recurrence of MM is also uncommon. We report 2 cases of pulmonary MM, the first involving primary MM of the lung and the second involving late recurrence 8 years after the initial surgery. Bronchoscopic punch biopsy identified MM in both cases. In the first case, work-up of the patient did not reveal any anomalies other than those in the primary site. In the second case, the patient had a history of thumb amputation for MM 8 years ago. For pulmonary MM, extrapulmonary origin of the tumor must be excluded by detailed examination because melanomas involving the lung are almost always metastatic. Whether the diagnosis is primary or metastatic disease, the potential for recurrence should be considered even in patients with a long disease-free survival.
Pleomorphic adenoma usually occurs in the salivary glands but rarely in the trachea or bronchi. A 71-year-old man had abnormal shadows on a chest X-ray. Chest CT revealed one tumor in the right basal segment of the lung and another, in the left main bronchus. Bronchoscopic biopsy of the right tumor revealed well-differentiated squamous cell carcinoma. Right lower lobectomy and lymph node dissection were performed (pT2N0M0, stage IB). At the orifice of the left main bronchus, bronchoscopy identified a polypoid lesion nearly obstructing the airway. The lesion was resected with hot snare ablation. The histological examination revealed a mixture of epithelial and myxoid mesenchymal elements, characterized by ductal structures, squamous metaplasia, and cartilage tissue. The diagnosis was bronchial pleomorphic adenoma coexisting with squamous cell carcinoma of the lung.
We present a rare case of adenosquamous carcinoma of the lung in a patient with complete situs inversus. The patient was a 76-year-old woman with the chief complaint of hemosputum. Chest X-ray and computed tomography (CT) scans of the thorax showed a mirror image of the organs and vessels and revealed a tumor 3.5 cm in diameter, in the left lower lung field. She was referred and admitted to KKR Hokuriku Hospital, Kanazawa, Japan to undergo surgery. Bronchoscopy showed a mirror image of the usual arrangement of the bronchi, and 5 segmental branches in the left lower bronchi. During surgery, care was exercised when intubation with the Univent® bronchial tube for one-lung ventilation. On thoracotomy, the gross appearance of the left lung and the arrangement of the pulmonary vessels and the bronchi corresponded to those normally found on the right side. We were successful in performing a left lower lobectomy. Postoperative diagnosis confirmed an adenosquamous carcinoma with localized pleural dissemination as p-t4n1m0, stage IIIa. Preoperative imaging, including CT, bronchoscopy, and angiographic examination of the patient, will be useful for prevention of vascular or bronchial injury during surgery in patients with complete situs inversus undergoing lung resection. Possible vascular or bronchial anomalies should always be taken into consideration while operating on these patients.
A 63-year-old male with lung cancer underwent a left upper lobectomy and mediastinal lymph node dissection through a median sternotomy. Postoperatively, he received 4 cycles of adjuvant chemotherapy with cisplatin and gemcitabin. Chest computed-tomography (CT) scan after the adjuvant chemotherapy showed a large cystic mass originating from the tracheal bifurcation. Fiberoptic bronchoscopy (FOB) revealed chylomediastinum during the aspiration biopsy of the mass. The chylous effusion was first removed by aspiration under FOB, though 2 weeks later the patient returned with a fever, and the CT lead us to suspect mediastinitis. After performing primary surgery for the removal of chylomediastinum, there was no recurrence thus we concluded that it was the better method.
Adults who have undergone surgical repair of congenital diaphragmatic hernia have a prolonged illness. They usually have severe adhesions around the intrathoracic hernial sac; therefore, the adhesion itself as well as misidentification of the hernial defect can make surgical repair difficult, even in open surgery. Here, we present the successful video-assisted thoracoscopic surgical repairs of Bochdalek and Morgagni hernias in patients with severe adhesions of the hernial sac (peritoneum) to the parietal pleura lying over the thoracic wall and diaphragm. An 18-year-old woman with a Bochdalek hernia and a 28-year-old woman with a Morgagni hernia underwent thoracoscopic division of severe adhesions, proper minithoracotomy, and precise repairs of diaphragmatic defects. Postoperative courses of both patients were uneventful with no signs of recurrence of the hernia. Thus, we recommend the thoracoscopic approach as the first choice over an open or laparoscopic approach in the management of adult patients with Bochdalek or Morgagni hernias and severe adhesion.
A 72-year-old man with a history of old myocardial infarction was admitted to our hospital for surgical treatment of a ruptured abdominal aortic aneurysm. His hemodynamics was stable. He had left lumbar pain on moving his left leg and constipation for ten days without abdominal pain and high fever. Elevation of fat density around the aneurysm and ureter involvement were noted on the computed tomography. These characteristic image findings indicated inflammatory aortic aneurysm. During operation, an infrarenal abdominal aortic aneurysm with an 8 cm maximum diameter was noted. This aneurysm was firm and thick and adhered to some organs due to inflammation. An 5 × 5 cm punched-out defect was found on the lateral wall of the aneurysm. We replaced the ruptured aneurysm with a Dacron graft. Histological examination showed that the aneurysm wall had an infiltrate of inflammatory cells, lymphoid follicles and thickened adventitia. From these findings, the diagnosis was inflammatory aortic aneurysm.
A 60-year-old woman was referred to the Department of Cardiovascular Surgery of Social Insurance Chukyo Hospital for the rupture of a postinfarction papillary muscle. The rupture was in the posterior part of the anterolateral papillary muscle, in which more than two-thirds of its posterior leaflet was prolapsed. Mortality from the surgical repair of a papillary muscle rupture is quite high. For this case, we resuspended the uninfarcted papillary muscle heads case to preserve mitral ventricular continuity because the mitral annulus was quite small and more than two-thirds of the posterior leaflet were detached from the papillary muscle. The post-operative course of the patient was uneventful. Resuspension of uninfarcted papillary muscle is a useful technique to repair a rupture in the papillary muscle.
Human immunodeficiency virus (HIV) infection has an impact on all systems of the body, including the cardiovascular system. A 54-year-old man presented with abdominal pain. Enhanced computed tomography revealed rupture of a pseudoaneurysm of the abdominal aorta. After surgery, the patient tested positive for HIV. Histological examination of the resected aorta showed leukocytoclastic vasculitis, a characteristic feature of HIV-related vasculitis.
A 79-year-old man with unstable angina developed localized left atrial tamponade after conventional coronary artery bypass grafting (CABG) with endoscopic radial artery harvesting (ERAH). Hemodynamic instability developed several hours after the systemic heparinization. Transthoracic and later intraoperative transesophageal echocardiography revealed a large, isolated hematoma compressing the left atrium. The radial artery for the circumflex artery bled during an emergent re-sternotomy. Incomplete hemostasis of the radial artery by ERAH was the likely cause of this serious complication. Surgeons, especially those who are new to ERAH, should examine the harvested radial arterial conduit carefully and confirm complete hemostasis before performing the procedure.
An 84-year-old woman with a history of surgery for cholangiocarcinoma presented to Akita University Hospital with severe right lower abdominal pain, respiratory distress, and hypotension. Computed tomography scanning revealed a ruptured right common iliac artery aneurysm with a massive right retroperitoneal hematoma and a right internal iliac artery aneurysm. Under the bilateral retroperitoneal approach, we preformed an in-situ repair of an aneurysm rupture from the aorta to the left common and right external iliac arteries using a bifurcated knitted Dacron graft, and then we ligated the right internal iliac artery. The postoperative course of the patient was uneventful. The patient was discharged from hospital 52 days after surgery. In conclusion, a bilateral retroperitoneal approach may be a safe and useful strategy for in-situ repair of a right iliac artery aneurysm rupture in patients with peritoneal adhesions after transperitoneal abdominal surgery.
Hepatic hydrothorax in the absence of ascites is a rare complication of liver cirrhosis. A 71-year–old man with liver cirrhosis due to alcohol abuse was referred to our department because of massive pleural effusion on the right side. The properties of pleural effusion and clinical course led to a diagnosis of hepatic hydrothorax. Nonsurgical OK-432 pleurodesis resulted in a marked decrease of pleural effusion. After 2 months of follow-up, effusion was well-controlled. Patients with hepatic hydrothoraces have few options. OK-432 pleurodesis is relatively safe and may provide an effective alternative to peritoneovenous shunt, transjugular intrahepatic portosystemic shunt or surgical pleurodesis. It may also be a bridge toward liver transplantation in patients with few other options. Herein, we report a case of refractory hepatic hydrothorax successfully treated by nonsurgical OK-432 pleurodesis.
We report a case of 68-year-old woman suffering from breathlessness on exertion with stridor. A chest computed tomography showed a tumor arising from the posterior wall of the trachea. The diagnosis was squamous cell papilloma of the surgically removed tumor, which had caused the asphyxiation. After removal of the tumor, the patient received radical therapy: semiconductor laser transpiration. Polymerase chain reaction (PCR) detected human papilloma virus (HPV) type 6, thought to be the cause of the respiratory papilloma.