The outcome of patients with T4 esophageal cancer, defined as a tumor that invades neighboring structures (e.g., aorta, trachea, bronchus, and lung), is extremely poor. Despite recent advances in surgical techniques, these tumors are usually considered inoperable. Two distinct therapeutic options are currently available for T4 esophageal cancers: chemo-radiotherapy followed by surgery (CRT-S), which comprises esophagectomy following down-staging of the tumor by CRT, and definitive chemo-radiotherapy (D-CRT), which is designed to avoid esophagectomy by using maximum doses of irradiation. CRT-S is superior to D-CRT with respect to local control and short-term survival although CRT-S is associated with relatively higher perioperative mortality and morbidity. On the other hand, it is sometimes difficult to achieve local control with D-CRT and the treatment often results in fistula formation, though a complete response to CRT is often associated with better prognosis. Admittedly, the difference in the survival rate between the two modalities is marginal at long-term follow-up due to operative morbidity and inadequate control of distant metastasis in CRT-S. Changes in perioperative management and intensive systemic chemotherapy may enhance the outcome. Randomized controlled trials involving large population samples are needed to define the standard treatment for T4 esophageal cancer.

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Background: Optimal resection type for non-small cell lung cancer (NSCLC) with interlobar lymph node involvement (ILNI) has seldom been reported. To completely resect a NSCLC with ILNI, some surgeons believe that a pneumonectomy is needed.
Methods: We retrospectively studied 151 patients (147 men, 4 women; mean age 58 ± 8 years, range 34–79) with non-small lung cancer without mediastinal or hilar lymph node metastasis who underwent an anatomic lung resection with systematic lymph node dissection between January 1995 and November 2006. All patients had involvement of the surgical-pathologic interlobar (#11) lymph node: 8 patients had a T1 tumor; 95, T2; 39, T3; and 9, T4. We evaluated the effect of resection type (pneumonectomy in 90 patients versus lobectomy in 61) on their prognosis by univariate and multivariate analyses.
Results: The 5-year survival rate of patients was 61% for the lobectomy and 35% for the pneumonectomy (p = 0.04). We did not find statistically significant differences in sex, median age, distributions of tumor site, histology and differentiation, complete resection rate, N1 involvement status, morbidity and mortality. Patients who underwent the pneumonectomy had larger tumors and more T3 tumors. The T status, multiple levels N1 involvement and histology did not affect survival in the univariate analysis. Multivariate analysis revealed resection type as a significant prognostic factor.
Conclusions: Pneumonectomy was not necessary in patients with NSCLC and interlobar lymph node involvement that we had discovered intraoperatively.

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Background and Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a sampling method for the patients with Non-small cell lung cancer (NSCLC) that have enlarged mediastinal lymph nodes that are detected with computed tomography (CT). We aimed to investigate the value of EBUS-TBNA in sampling enlarged mediastinal lymph nodes in the patient with NSCLC.
Patients and method: From January 2007 to May 2009, patients were diagnosed NSCLC with CT scans showing enlarged lymph nodes (node >1 cm) or a positron emission tomography (PET/CT) finding of the mediastinum underwent EBUS-TBNA.
Results: EBUS-TBNA was successfully performed in all 52 patients (mean age, 52 years; 45 men) from 93 mediastinal lymph nodes. EBUS detected lymph node metastasis in 40 patients (77%). 12 patients (23%) with negative lymph node samples were underwent mediastinoscopy. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EBUS-TBNA in the detection of mediastinal metastasis were 95 %, 100%, 100%, 83%, and 96%, respectively. EBUS-TBNA was uneventful, and there were no complications.
Conclusion: EBUS-TBNA is an effective, safe and minimally invasive procedure following PET/CT or CT scanning in the mediastinal staging of potentially operable NSCLC.

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Background: There has been an evolving role of surgery for malignant pleural mesothelioma (MPM) over the past 25 years. The objective of this study was to investigate whether the survival results for MPM patients after surgery have improved within this time period by an analysis of a prospective cohort of 540 patients.
Methods: Five hundred and forty consecutive patients with MPM were treated by a thoracic surgical team. These patients were categorized into two groups: Group I (before September 1999, n = 270) and Group II (after September 1999, n = 270). The two groups were compared for clinicopathologic data and survival results. The statistical analyses of all prognostic parameters used overall survival as the endpoint.
Results: Group II had higher proportions of epithelial tumors and patients who had preoperative PET scan, extrapleural pneumonectomy (EPP), postoperative radiotherapy and pemetrexed chemotherapy. The overall survival results were significantly better in Group II compared with Group I (p = 0.004). Four factors were found to be independently associated with an improved survival in multivariate analysis: epithelial subtype (p <0.001); surgeon’s experience with >100 cases (p = 0.006), patients who underwent EPP (p = 0.001) and those who received pemetrexed chemotherapy (p = 0.016). The median survival for patients selected for EPP was 20 months, as compared to 9 months for pleurodesis/decortication and pleurodesis.
Conclusions: Significant improvement of overall survival results has been achieved in the more recent 270 MPM patients through accumulated experience in a specialist treatment center.

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Purpose: It is critical to differentiate among pathologies of substernal thyroid gland diseases because surgical approaches (i.e., median sternotomy or thoracotomy) might also include a cervical incision. The aim of this study was to analyze the features of patients with goiter who underwent a thyroidectomy via a cervical incision and a median sternotomy or thoracotomy.
Methods: We reviewed 9 cases of thyroid disease in patients undergoing thoracic incisions with or without a cervical incision for varying indications between March 2003 and Jun 2009 were reviewed. Thyroidal masses were removed via a median sternotomy in six patients and thoracotomy in three patients. Split median sternotomy combining thoracotomy was performed in 1 patient. Cervical incision was added in all patients.
Results: Pathologic examination revealed multinodular goiter in 5 patients, thyroid carcinoma in 3, and reidel thyroiditis in 1. All patients were extubated in the early postoperative period. There was no postoperative mortality or morbidity. The mean hospital stay was 8.6 days (range, 4–11 days), and mean follow-up was 24.3 months (range, 4–39 months).
Conclusions: We recommend the use of transthoracic approaches, such as median sternotomy and thoracotomy for retrosternal goiter for surgical exposure, because they provide a wide exposure and facilitate removal of the mass. By using median sternotomy and thoracotomy, we can avoid catastrophic results, such as hemorrhage, as well as completely remove malignancies.

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Background: Achalasia is a primary esophageal motor disorder involving the body of the esophagus and lower esophageal sphincter. The mechanism is destruction of the myenteric plexus after a viral infection. Multiple methods of treatment with variable results induced in achalasia.
Materials and Methods: We analyzed 70 patients with achalasia that underwent surgical treatment with transabdominal or transthoracic cardiomyotomy from 1982 to 2008 in Mashhad (Ghaem and Omid) hospital and at least 2 years follow up for evaluated result of surgery.
Results: The mean age was 39.2 ± 9.42 years and the M/F = 0.89. The most common symptom was dysphagia (100%). The interval between beginnings of symptoms to a definitive diagnosis was 10.6 ± 8.3 month. The ratio between the two techniques was 35/35 = 1. In 67.1% of patients, a previous history of pneumatic dilation was reported. Long-term good results after surgery were seen in 77.2% of patients. Recurrence after surgical treatment was seen in 22.8%. A comparison of the two techniques (with or without antireflux surgery), showed a greater failure rate in transabdominal cardiomyotomy without the antireflux protocol (8/15 = 40%), but by the chi- square test, the difference was not statistically significant (P = 0.107). The most common complication after surgery was esophageal leakage (2.85%), and mortality was zero. In recurrence, most patients underwent pneumatic dilation (9/16 = 56.2%), and if surgery was needed, all patients underwent a transthoracic approach with antireflux treatment.
Conclusion: Based on the good, long-term results with the surgical treatment of achalasia, surgery is recommended in most patients. A transthoracic or transabdominal approach had good, long-term results, but a transthoracic approach had better results and usually did not need antireflux surgery.

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Objective: Operative stress of cardiovascular surgery can alter the blood levels of various physiologically active substances (e.g., cytokines, growth factors), and thus potentially affect cancer cell proliferation. How the combination of changes in blood levels of these substances affects cancer cells has not been adequately addressed. We investigated the stimulatory capacity on cancer cells of serum from patients after cardiovascular surgery, using a novel in vitro assay method.
Methods: The subjects were 22 patients undergoing cardiovascular surgery, consisting of 11 off-pump and 11 on-pump procedures. Blood was sampled from each subject immediately before surgery, immediately after surgery, and after transfer to the intensive care unit. Human lung cancer cells were exposed to the serum of each blood sample from each patient, and an MTT assay was conducted to evaluate cell proliferation.
Results: Serum samples of all patients showed an inhibitory effect for lung cancer cell proliferation. This inhibitory effect was lower in postoperative serum compared with serum samples before surgery. As a result, lung cancer cell proliferation was better with postoperative serum samples than preoperative serum samples. The proliferation rate after surgery, when it was compared with preoperative serum, was significantly higher in patients with on-pump procedures than in patients with off-pump procedures.
Conclusion: The results of this study suggest that the operative stress of cardiovascular surgery induces changes in serum to make it less inhibitory for the cancer cell proliferation. This phenomenon is greater in patients with extracorporeal circulation.

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Purpose: We evaluated a treatment strategy for acute myocardial infarction (AMI) that percutaneous coronary intervention (PCI) is performed on a culprit lesion unless the culprit is an unprotected left main trunk. Emergent coronary artery bypass grafting (CABG) is done when the culprit is a left main trunk and a mechanical complication exists.
Methods: From 1997 to 2008, 22 and 232 patients underwent CABG for AMI and non-AMI, respectively. Of the 22 patients of AMI, PCI was performed in 12 patients and not performed in 10 patients before surgery. We investigated complication, intubation period, in-hospital mortality and hospitalization period.
Results: No in-hospital mortality was observed in all 22 AMI patients. There was no difference in in-hospital mortality and complication between the AMI and the non-AMI patients. No significant difference was found in hospital stay, complication, intubation period, in-hospital mortality and hospitalization period between patients who received preceding PCI and not.
Conclusions: These results suggest that our treatment strategy is reasonable. Further studies will be warranted to clarify the role of preceding PCI.

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Background: CRT (atrial-synchronized bi-ventricular pacing) has been shown to significantly improve the quality of life and exercise tolerance in patients with moderate-severe heart failure and an interventricular conduction delay (>120 msec) when compared to controls. Traditionally it has been performed by cardiologists in electrophysiology laboratories. In the event that the left ventricular lead cannot be positioned percutaneously the procedure is aborted and the cardiac surgeon consulted. The subsequent intervention by the surgeon, typically on another day, requires reexploration of the pocket, a thoracotomy, which results in an increase in length of stay (LOS), and an increase in infection risk. The objective of this study was to demonstrate that CRT could routinely be performed in a surgical operating room (OR) as a single rather than a staged procedure.
Methods: Between 1/1/06 and 7/1/06 18 patients (17 male and 1 female) with an average age of 56 years (range 36–79) underwent CRT. Transthoracic echo (TTE) revealed that all had left ventricular ejection fractions (LVEF) <30% (range 8%–28%). Five of the 18 had moderate-severe mitral regurgitation (MR). The etiology of the cardiomyopathies was ischemia in 4 and non-ischemia in 14. All had QRS intervals >120 msec (range 120–200 msec) and all were maintained preoperatively on their conventional therapy for heart failure (B-blockers, ± diuretic, ± ACE-I or ARB) and all were either New York Heart Association (NYHA) functional class III or IV. Every case was performed under general anesthesia with an arterial line and Foley catheter in the semi right lateral decubitous position. Nine of the 18 patients underwent a left anterolateral mini-thoracotomy for epicardial left ventricular (LV) lead placement. All hardware included defibrillation technology (ICD).
Results: All 18 patients left the OR with successful bi-ventricular pacing in an average time of 170 minutes (range 140–200 min). The average epicardial lead pacing threshold was 0.9v (range 0.4–1.5v) while the average endocardial (transvenous) threshold was 0.4v (range 0.2–0.7v) at a pulse width of 0.5 msec. TTE at 1 month demonstrated an improvement in LVEF in 14/18 patients with an average increase of 5% (range 2%–9%). Four of the 5 patients with moderate-severe MR were reduced to mild. The average length of stay (LOS) following the procedure, in those patients who did not undergo a thoracotomy, was 4 days (range 3–6 days) while it was 7 days (range 6–10 days) in those who underwent a thoracotomy.
Conclusion: These data clearly indicate that CRT can be successfully performed as a single-staged procedure in a cardiac OR. Although transvenous LV lead placement avoids a thoracotomy, the epicardial LV lead thresholds, in this series, are competitive with the transvenous results. We propose that in the spirit of cost containment, fee bundling, decreasing reimbursement, pay-for-performance, and infection control, these complex interventions should be performed in multipurpose interdisciplinary hybrid cardiac OR’s, now available in most major medical centers, with designated time limitations and role assignments.

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Purpose: The purpose of this study was to evaluate the accuracy of plasma cystatin C in acute impairment in renal function; plasma cystatin C was compared to plasma creatinine in two hundred patients undergoing elective CABG surgery.
Methods: We performed a prospective clinical study of two hundred patients undergoing coronary bypass surgery. Plasma creatinine and cystatin C were measured preoperatively and on the first and fourth days after surgery. Estimated glomerular filtration rate (GFR) was calculated using one creatinine-based and two cystatin C-based equations.
Results: There were 144 non-diabetic and 56 diabetic patients. The need for furosemide was more common among diabetics (80.4% of the patients vs. 53.9%, p = 0.024). Changes in cystatin C-based GFR with both equations were significantly greater in the group of diabetics (-14.3 ± 28.0 and -11.2 ± 19.3 ml/min/1.73 m² vs. -4.3 ± 26.9 and -3.1 ± 20.5 ml/min/1.73 m², p = 0.025 and 0.016, respectively). Changes in creatinine-based GFR did not differ between the diabetics and the non-diabetics.
Conclusion: Cystatin C and cystatin C-based estimation of GFR may be useful and more sensitive than creatinine in detecting mild acute renal insufficiency in diabetic patients.

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Upper airway obstruction due to subglottic mass can be misdiagnosed. We report the case of a 66-year-old man who was treated for chronic obstructive pulmonary disease (COPD) before a diagnosis of pleomorphic adenoma of the subglottis was made. According to the history of chronic cough and exertional dyspnea, he was treated with inhaled corticosteroids for COPD. Bronchoscopy and computed tomography (CT) revealed a mass occupying the subglottic cavity. After the excision operation, all symptoms disappeared. Histological evaluation revealed the diagnosis of pleomorphic adenoma. This case report emphasizes that not all chronic cough and dyspnea are attributable to COPD.

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The aortic root of a 30-year-old man was replaced with a Freestyle stentless aortic bioprosthesis for aortic regurgitation associated with annuloaortic ectasia. His clinical course was uneventful, and he was discharged without complications. Three years and six months after surgery, he presented with a high fever. Four years after surgery, transthoracic echocardiography revealed severe aortic regurgitation. We performed exploratory surgery and discovered a torn left coronary cusp of the Freestyle bioprosthesis. Organized vegetation was adherent to the left coronary cusp leaflet. The non-coronary cusp and the right coronary cusp were normal. The diagnosis was aortic regurgitation due to valve failure related to infective endocarditis. Consequently, we reconstructed the aortic root with a composite graft (26-mm Valsalva graft and a 21-mm ON-X mechanical valve).

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A 65-year-old male, having symptoms suggestive of pulmonary malignant tumor, underwent video-assisted thoracic surgery (VATS). Surgery revealed a solid tumor originating from the thoracic wall, with many small solid tumors in the thoracic wall and diaphragm near the tumor. The intraoperative observation of a frozen section typed the tumor as carcinoid; however, hematoxylin-eosin staining and immunohistological findings provided the definitive diagnosis of diffused, malignant pleural mesothelioma (MPM).

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We present a case of a solitary fibrous tumor of the pleura with sudden onset, recurrent hypoglycemia. A 76-year-old smoking male with type-II diabetes mellitus admitted to our hospital for dyspnea and general malaise. Radiological findings revealed a large tumor occupying the right hemithorax. After bronchoscopic examination, the patient developed a fever and began to wheeze. Treatment with antibiotics and several other drugs improved his symptoms. Percutaneous needle biopsy confirmed the diagnosis. After these medical interventions, the patient suddenly developed recurrent hypoglycemia. After the right pneumonectomy, the patient never experienced hypoglycemia again. We should consider the possible relation between hypoglycemia and solitary fibrous tumor of the pleura, even when the patient is not hypoglycemic during the initial examination.

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Excision of a neurogenic tumor of the brachial plexus positioned high in the mediastinal space could potentially result in a functional disorder of the arm. We report on a case in which we performed evoked potential monitoring on a tumor located high in the mediastinum. We found large potential changes in the median and ulnar nerve areas and had a concern that the excision might injure the brachial plexus. We did a biopsy and intraoperative rapid histological diagnosis, which promptly revealed that the tumor was not malignant. Thus, we decided not to excise the tumor because the procedure could possibly injure nerves in the arm.

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A 59-year-old woman with a history of von Recklinghausen’s disease (VRD) suffered sudden chest pain. Enhanced chest computed tomography showed massive hemothorax, but no evidence of tumors or an obvious bleeding point in the thorax. After we had ensured a stable hemodynamic condition, we performed video-assisted thoracic surgery to remove the hematoma. The bleeding point was in a branch of the right subclavian artery. We performed direct surgical ligation of the bleeding vessel with a fibrin tissue-adhesive collagen fleece. Recovery was uneventful, and the patient is now doing well with no evidence of re-bleeding, 12 months postoperatively. Spontaneous hemothorax in patients with von Recklinghausen’s disease represents a critical event, and exploratory video-assisted thoracic surgery appears useful in the removal of clotted blood and reinforcement of fragile arteries for the prevention of re-bleeding. We should recognize this rare and critical condition in patients with von Recklinghausen’s disease.

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Sclerosing mediastinitis is a rare, benign disorder that is often indistinguishable from malignancy by conventional imaging techniques. The value of fluorodeoxyglucose positron emission tomography (FDG-PET) imaging in the diagnosis of this disorder has not been elucidated. Recently, a few studies have reported the use of dual-phase FDG-PET imaging in the diagnosis of malignancies. The dual phase contains early- and late- phase images. The maximum standard uptake value (SUVmax) of late phase images of malignant lesions tends to be higher than those of early phase images. The present case showed that early-phase SUVmax was 5.93, and late phase, 8.92. We strongly suspected malignancy from the results of this new imaging technique, though the histological examination of the surgical samples provided the definitive diagnosis of sclerosing mediastinitis, Flieder stage II. This report describes the uncommon use of dual-phase FDG-PET computed tomography in the preliminary diagnosis of sclerosing mediastinitis. It is thought that current imaging studies are insufficient for the diagnosis of sclerosing mediastinitis, and the rarity of this disorder may prevent the development of imaging techniques. Histological confirmation is still essential for the definitive diagnosis of this disorder.

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We report a case of a 66-year-old man who presented with an abnormal sensation, tenderness, and pain in the middle of his chest in May 2006, two years after a mitral valve replacement for severe mitral regurgitation and a MAZE operation for chronic atrial fibrillation elective cardiac. He was immediately admitted, and the x-ray examination revealed an abnormal elongation of the xiphoid process. At the time of discharge after the initial operation in 2004, x-rays indicated that the length of the xiphoid process was 3 cm; however, in 2006 it had elongated to 6 cm and was prominent in the anterior view. The patient underwent surgical extirpation of the xiphoid process while he was under local anesthesia. Histological examination of the resected xiphoid process revealed no signs of neoplastic or maligant change. The cause of the elongation of the xiphoid process was believed to be distraction tissue neogenesis. The xiphoid process, which fractured and separated from the sternum at the initial operation, was pulled down inferiorly by the rectus abdominis muscles, following which the xiphoid process became elongated and reconnected with the sternum. In cases of a fractured or amputated xiphoid process after median sternotomy, the xiphoid process should be resected to avoid its neogenesis.

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A paraganglioma is a rare tumor that develops out of extra-adrenal chromaffin cells and pheochromocytomas originating from the adrenal medulla. Early diagnosis and surgical planning are crucial, since the tumor secretes catecholamine and is adjacent to large vessels in the abdomen. Furthermore, since complete resection improves the prognosis, we recommend a meticulous surgical technique. Here, we present a case of paraganglioma in a 32-year-old male patient who initially presented with a stomachache. After conducting the required tests, we resected the tumor that was pressing against the vena cava in the interaortocaval region.

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Penicillin-resistant Streptococcus pneumoniae (PRSP) infections have steadily increased worldwide; however, there are only a few reports of permanent pacemaker-related infections caused by PRSP. Here, we describe a patient who developed 7 episodes of endocarditis and sepsis from PRSP infection of the pacemaker lead in the right atrium. By periodic administration of vancomycin and extraction of both leads, we resolved the infection.

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A 73-year-old woman with a 10-year history of myelodysplastic syndrome (MDS) had severe aortic regurgitation (AR) and an ascending thoracic aortic aneurysm (TAA) with a maximum diameter of 55 mm. By retrograde cerebral perfusion (RCP) in the patient under deep hypothermic circulatory arrest (DHCA), we replaced the ascending aorta graft and aortic valve. After surgery, we periodically administered granulocyte colony-stimulating factor (GCSF) with platelet aggregation. On postoperative day 20, the patient had a duodenal ulcer. On postoperative day 22, she had a subarachnoid hemorrhage, which was treated, nonoperatively, with a hemostatic agent. On postoperative day 126, she was discharged without sequelae, and 1.5 years after the surgery, she has had neither heart failure nor deterioration of MDS.

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We report the case of an 82-year-old man who underwent triple coronary artery bypass grafting with arterial grafts, who 20 years previously underwent left pneumonectomy for lung cancer. Computed tomography (CT) presented a marked shift of the heart and great vessels into the left hemithorax. Off-pump coronary artery bypass grafting was performed through a left thoracotomy, in which the left internal thoracic, right gastroepiploic, and radial arteries were used. He was extubated 1 hour post-operatively and had an uneventful recovery.

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Pseudoaneurysm of the ascending aorta after cardiac surgery is a rare but life threatening complication, which can result in rupture. Pseudoaneurysms are usually related to the aortic cannulation, the proximal site of graft anastomosis, or the suture line of aortotomy, and often occur after mediastinal infection. We report a case of pseudoaneurysm of the ascending aorta associated with aortic cannulation and the proximal anastomosis of a saphenous vein graft without an obvious history of mediastinal infection.

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