In Japanese surgical society, there have been urgent discussions as to the decrease in the number of junior doctors who want to be surgical specialists. This problem seems to have originated from the loss of attractiveness of surgery. One of the counter-measures to regain the attractiveness of surgical specialties might be a well-organized training system, for which the Japanese Board of General Thoracic Surgery (JBGTS), as well as those of other surgical subspecialties, has struggled. Fortunately, I had an opportunity of general thoracic surgery training in Canada, and had a chance to reflect on the thoracic training programs of both countries. Based on my experience as a thoracic fellow in Canada, I would like to introduce the Canadian way of thoracic surgery training, referring to the differences between each program.
The aortic root has a unique 3-dimensional configuration and the distinctive function of supporting the aortic valve and blood vessels. The sinuses of Valsalva are crucial to create appropriate eddy currents that are important in initiating and coordinating aortic valve closure and promoting coronary artery blood flow. Most aneurysms in the aortic root are associated with degenerative changes in the elastic media rather than atherosclerosis. Valve-sparing root repair has become widely accepted, although the Bentall procedure remains the gold standard. Because reimplantation using the Valsalva graft allows root geometry to be retained and theoretically and practically prevents recurrent aortic valve regurgitation, it is considered the most reliable and preferred technique among various valve-sparing aortic root repair procedures.
A method of videothoracoscopy-assisted extended thymectomy procedure performed through a movable small access window is introduced. The access window can be moved stepwise and longitudinally alongside full sternotomy to be upon the dissection site. The majority of the thymectomy procedure can be directly viewed and operated from the moving window. However, partial and complete thoracoscopic maneuvers are required for dissection of the lateral-most region near the phrenic nerve and the upper poles of the thymus, respectively.
Objectives: Video-assisted thoracoscopic surgery (VATS) segmentectomy for small or early stage non-small cell lung cancer (NSCLC) remains controversial. Here, we investigated the clinical importance of predicting recurrence by Ki-67 in VATS segmentectomy for stage I NSCLC. Methods: In a retrospective study, 44 consecutive patients in p-stage I underwent VATS segmentectomy between September 2003 and April 2009. After clinicopathological factors were compared with Ki-67 expression, the relationship between Ki-67 labeling indexes (LI) or mRNA expression by quantitative RT-PCR and prognosis was investigated. Results: Five of 44 VATS segmentectomy patients relapsed. In the relapsed patients, 3 (6.8%) were local recurrences and 2 (4.5%) were distant metastases. There was no significant difference between clinicopathological factors and recurrence; however, patients with Ki-67 LI less than 5% showed better disease-free survival than patients with Ki-67 LI over 5% (p = 0.04). In multivariate Cox regression analysis, although there was no significantly different in disease-free survival by age, histology, tumor size, only Ki-67 LI showed a significant prognostic factor of recurrence (HR = 12.5, 95% CI = [1.1-1407], p = 0.04). Conclusions: Ki-67 LI after VATS segmentectomy was a prognostic factor of disease-free survival in NSCLC and the treatment of choice for patients with positive LI may be considered, in addition to adjuvant chemotherapy, or lobectomy.
Objective: The present paper exemplary describes several severe stenoses of supraaortic branches with its symptoms and operative treatments. Methods: Eight patients, two female (68 ± 5 y), six male (73 ± 4 y), were retrospectively evaluated. Patients showed neurological signs as followed: recurring attacks of vertigo (80%), temporary paresis of extremity (20%), speech disorders (20%) and subclavian and/or carotic-steel-syndrome (15%). Seven patients have already been previously treated with revascularization of the supraaortic branches in the past. The surgical techniques used were thrombendarterectomy of the internal carotid artery, carotid-subclavian bypass and complex aorto-truncal, aorto-carotid and aorto-subclavian-bypass. Results: One patient died nine days postoperatively due to myocardial infarction. Mean duration of stay on intensive care unit was 1.5 days. Mean duration of postoperative ventilation was six hours. Average duration of stay on normal ward was nine days. Conclusion: This study presents several complex reconstructions of supraaortic branches, which were indicated in cases with severe stenoses of supraaortic branches. Even though treatment strategies were complex the peri- and postoperative complication rates are quite low. These therapeutic strategies were necessary to avoid severe neurological complications in these patients.
Objective: Continuous veno-venous hemodiafiltration (CVVH) is used as one of the modalities of continuous renal replacement therapy (CRRT) in pediatric intensive units. The aim of our study was to investigate the use of CVVH in small children with acute renal failure (ARF) after cardiac surgery. Patient and Methods: Between June 2005 and June 2008, 7 patients who required dialysis after pediatric cardiac surgery without ECMO underwent CVVH with polymethylmethacrylate membrane (PMMA) treatment. The definition of ARF was based on a 100% rise in serum creatinine (Cr) concentration, oliguria. On the other hand, PMMA-CVVH was weaned in patients with satisfactory urine output, stable biochemical markers of renal function and adequate fluid balance. Results: All patients treated with PMMA-CVVH alone (4 boys, 3 girls) had a median age of 36 months and a median body weight of 11kg. The averaged established time from cardiac operation to CVVH was 2.6 days. There was a significant decrease in the post-filter compared with pre-filter levels of BUN, Cr, potassium concentration. There were no significant changes in systolic blood pressure, lactate level and CRP; however, it was unnecessary for all patients to use epinephrine. Conclusions: Continuous veno-venous hemodiafiltration with PMMA-CVVH without ECMO achieved a surprisingly Zero mortality.
Background: The Maze procedure in patients without mitral valve disease remains controversial, because of the increased invasiveness and operation time required to create additional incisions in the atria. The ain of this study was to assess prognosis following the Maze procedure in patients without mitral valve disease. Methods and Results: One hundred and seven consecutive patients who underwent the Maze procedure between 2002 and 2008 was enrolled in this study. Patients were divided into two groups based on the presence or absence of mitral valve disease. Freedom from atrial fibrillation was compared by multivariate logistic regression analysis at discharge. The Kaplan-Meier method and Cox-proportional hazard analysis adjusted for other predictors were estimated to compare freedom from atrial fibrillation at follow-up. Follow-up was 98% complete and mean duration of follow-up was 457 days. Operation and aorta cross-clamp times were similar between groups. No differences were identified in freedom from atrial fibrillation at discharge (non-mitral valve surgery, 55% vs. mitral valve surgery, 66%) or follow-up (57% vs. 61%, respectively). In multivariate Cox proportional hazard modelling, the presence of mitral valve disease was not associated with a poor success rate of conversion. Conclusions: Results of the Maze procedure for atrial fibrillation without mitral valve disease were acceptable. The Maze procedure could be a beneficial option for these patients to avoid adverse events of atrial fibrillation.
Purpose: Chronic kidney disease (CKD) is an independent risk factor for cardiovascular disease. We investigated the effectiveness of human atrial natriuretic peptide (hANP) infusion in CKD patients undergoing coronary artery bypass grafting (CABG). Patients and Methods: We analyzed 134 consecutive cases in which CABG had been performed in our hospital from 2002 to 2005. They were divided into four groups: Group A (n = 19) was CKD + placebo, Group B (n = 30) was non-CKD + placebo, Group C (n = 22) was CKD + hANP, and Group D (n = 63) was non-CKD + hANP). The serum creatinine (mg/dl) and estimated glomerular filtration rate (ml/min/1.73 m2) were measured as evaluation values. Results: The value of sCr changed preoperatively and at 1 year postoperatively from 1.09 ± 0.09, 51.3 ± 4.4 to 1.26±0.42, 49.4±14.4 in Group A, from 0.77 ± 0.14, 75.5 ± 12.1 to 0.91 ± 0.40, 72.3 ± 19.5 in Group B, from 0.99 ± 0.12, 54.8 ± 3.0 to 0.93 ± 0.16, 64.2 ± 12.3 in Group C and from 0.77 ± 0.13, 77.7 ± 13.4to 0.83 ± 0.17, 75.9 ± 16.2 in Group D, respectively. There was a significant difference between Group A and Group C regarding the change of creatinine (p =0.0022) Conclusion: Our study has confirmed that an infusion of hANP during CABG in patients with CKD not only improves perioperative renal function, but also prevents the progression of CKD.
Patients who undergo thoracic aortic surgery with deep hypothermia frequently have postoperative respiratory failure as a complication. Severe lung injury in these patients results in a fatal outcome. A specific neutrophil elastase inhibitor, sivelestat sodium hydrate, is an innovative therapeutic drug for acute lung injury. We evaluated the protective effects of sivelestat sodium hydrate on severe lung injury after thoracic aortic surgery with deep hypothermia. From January 2002 to July 2007, 71 consecutive patients underwent thoracic aortic surgery with deep hypothermia. Of these patients, 22 had postoperative respiratory failure with PaO2/FiO2 ratios of less than 150. They were randomly assigned to one of two groups. The first group (Group S, n = 10) was administered sivelestat sodium hydrate continuously at 0.2 mg/kg/h until weaning from mechanical ventilation; the second group (Group C, n = 12) was not administered sivelestat sodium hydrate. The groups were comparable with respect to clinical data. There were no significant differences between the two groups in age, operation duration, total cardiopulmonary bypass time, circulatory ischemia time, cardiac arrest time, intraoperative blood loss, and total transfusion volume. The improvement of pulmonary function was observed in the both groups, but more marked in Group S by statistical analysis using analysis of variance for repeated measurements. Especially, in the early phase, pulmonary function improvement was more marked in Group S. The duration of mechanical ventilation, the length of stay in the intensive care unit, and the length of hospital stay were shorter in Group S, but not significantly. Sivelestat sodium hydrate is a specific neutrophil elastase inhibitor that improves pulmonary function in patients with severe postoperative respiratory failure following thoracic aortic surgery with deep hypothermia. The drug may shorten the duration of postoperative ventilation, intensive care unit stay, and hospital stay.
Objective: Recent studies have demonstrated that statins have pleiotropic effects, including anti-inflammatory effects and atrial fibrillation (AF) preventive effects. The objective of this study was to assess the efficacy of preoperative statin therapy in preventing AF after coronary artery bypass grafting (CABG). Methods: 221 patients underwent CABG in our hospital from 2004 to 2007. 14 patients with preoperative AF and 4 patients with concomitant valve surgery were excluded from this study. Patients were divided into two groups to examine the influence of statins: those with preoperative statin therapy (Statin group, n = 77) and those without it (Non-statin group, n = 126). In addition, patients were divided into two groups to determine the independent predictors for postoperative AF: those with postoperative AF (AF group, n = 54) and those without it (Non-AF group, n = 149). Patient data were collected and analyzed retrospectively. Results: The overall incidence of postoperative AF was 26%. Postoperative AF was significantly lower in the Statin group compared with the Non-statin group (16% versus 33%, p = 0.005). Multivariate analysis demonstrated that independent predictors of AF development after CABG were preoperative statin therapy (odds ratio [OR] 0.327, 95% confidence interval [CI] 0.107 to 0.998, p = 0.05) and age (OR 1.058, 95% CI 1.004 to 1.116, p = 0.035). Conclusion: Our study indicated that preoperative statin therapy seems to reduce AF development after CABG.
Background: Chronic heart failure after myocardial infarction is still a serious problem without a fundamental therapy. Experimental transplantation of bone marrow cells (BMC) into infarcted myocardium resulted in regeneration and functional improvement. Objective: Clinical investigation of safety and efficacy of intracardiac transplantation of unselected autologous BMC. Method: 22 patients scheduled for elective and isolated coronary artery bypass grafting (CABG) with a reduced LVEF due to myocardial infarction were included. Intraoperatively, sternal bone marrow blood was aspirated, and a sterile buffy coat was prepared and applicated. 19 age, LVEF and coronary disease matched patients served as controls. Heart function, geometry, and scar proportion were assessed by echocardiography and Gadolinium-MRI at the time of the operation and 6 months thereafter. Results: Transplanted patients received a mean number of 360 × 106 BMC. We did not notice any significant differences in early or late complications in the transplant group as compared to controls. At six months follow up only the transplanted patients showed a significant improvement of NYHA classes from 2.7 to 1.5 and of LVEF from 36 to 43 %, (p < 0.05). Furthermore, only CABG concomitant with BMC-TX led to a significant reduction of left ventricular end diastolic diameter (LVEDD) from 59 to 54 mm and of scar proportion of the infarcted segments from 2.53 to 2.42, (p < 0.05). Conclusion: Intracardiac transplantation of unselected, autologous BMC is safe and feasible. In adjunct with coronary revascularization it leads to an improvement of ventricular geometry and function. Moreover, it reduces myocardial scar proportion and heart failure symptoms.
This is the first report of adalimumab-associated pulmonary cryptococcosis. A 56-year-old female with rheumatoid arthritis without a history of pulmonary disease was simultaneously administered adalimumab (40 mg/2 wks), methotrexate (4 mg/wk), and isoniazid (200 mg/day). Five months later, chest radiography revealed a small spiculated pulmonary nodule, and the laboratory test results, including levels of tumor markers and plasma β-D-glucan, were within normal ranges. Since the lesion continued to grow, even after discontinuing adalimumab, it was surgically resected. Grocott staining of the tissue sample revealed black-brown fungi, identified as Cryptococcus neoformans in culture. The patient now remains well, without adalimumab therapy.
We present the case of a 67-year-old male smoker with a posterior mediastinal hemangioma. Radiological findings revealed a dumbbell-shaped tumor with a neuroforaminal extension in the right paravertebral space. Under the preoperative diagnosis of a neurogenic tumor, surgery was performed using a combined anterior and posterior approach. During the thoracotomy, the tumor was found to be a hemangioma. We ligated the involved vessels before performing laminectomy, thus ensuring that complete tumor resection was achieved without massive bleeding in the spinal canal. Dumbbell-shaped hemangiomas are rare, and preoperative confirmation of the diagnosis is challenging. Thoracotomy before laminectomy is optimal for the resection of dumbbell-shaped tumors of the mediastinum, especially with marked vascularity, given that the initial thoracotomy procedures facilitate the subsequent laminectomy procedures.
An adolescent female was admitted to the pediatric intensive care unit in septic shock. She developed multisystem organ dysfunction including pancreatitis with myocardial dysfunction and hemodynamic instability unresponsive to medical management necessitating veno-arterial extracorporeal support. Streptococcus Constellata and Fusobacterium necrophorum were isolated from blood cultures. This is the first report of extra-corporeal cardiac support in fusobacterium sepsis.
A 43-year-old woman presented to us with progressive breathlessness, dry cough and weight loss. A chest radiograph showed homogeneous opacification of the entire left hemithorax. A contrast enhanced computed tomography (CECT) scan of the thorax showed a large intrathoracic mass occupying almost the entire left hemithorax and appeared grossly inoperable. A transcutaneous CT guided tru-cut biopsy revealed a solitary fibrous tumour. We reviewed the CT scans based on the biopsy report, and, in retrospect, the mediastinal vessels seemed more stretched and pushed by the tumor rather than directly infiltrated by it. We performed an exploratory thoracotomy and to our surprise, were able to dissect the mass quite easily off the mediastinum. She had an uneventful postoperative recovery, and the final histopathology confirmed a solitary fibrous tumor. We report this case to emphasize that a cursory clinico-radiological interpretation can dissuade surgical intervention in these patients.
Pulmonary metastasis from carcinoma of the papilla of Vater is considered to be a late event, and patients can be treated with radiotherapy, chemotherapy, or palliative surgery. However, surgical treatment of an isolated lung metastasis has not been reported. We present a surgical case of solitary pulmonary metastasis from carcinoma of the papilla of Vater. A 51-year-old man underwent pylorus-preserving pancreaticoduodenectomy for Vater carcinoma. During follow-up, chest computed tomography revealed a nodular shadow in the right lung. The pathological examination demonstrated the appearance of the pulmonary tumor resembled that of the previously resected Vater carcinoma, and both tumors showed similar immunostaining properties, leading to the pathological diagnosis of pulmonary metastasis from carcinoma of the papilla of Vater. Isolated pulmonary metastasis from carcinoma of the papilla of Vater is extremely rare, but surgery could be the treatment of choice.
We report our experience with an unusual case of sclerosing hemangioma (SH) that formed a pedunculated mass protruding into the thoracic cavity. A pulmonary tumor was found in a 60-year-old female during the medical examination. Computed tomography showed a 19 × 17-mm nodule with a clear border and smooth margin contiguous with the diaphragm in the right S8 segment. Uneven enhancement following contrast medium administration was observed. We performed a 3-port thoracoscopic wedge resection of the right lower lobe. We observed a yellow pedunculated tumor protruding from the diaphragmatic surface of the right lower lobe. The surface of the tumor was smooth and encapsulated. Microscopically, we diagnosed it as a SH. SHs usually exist adjacent to the visceral pleura, but rarely form pedunculated tumors protruding into the cavity as seen in this case. By thoracoscopic surgery, we successfully diagnosed and treated the patient in a minimally invasive manner. Since there have been reported cases of recurrence, we anticipate that periodic follow-up observations will be required.
A 73-year-old woman was referred for treatment of left atrial (LA) myxoma. At surgery, a myxoma was attached to the left atrial side of the fossa ovalis in the atrial septum by a stalk and was transmurally excised with a margin of the atrial septum. The atrial septum was closed without any prosthetic materials under mild to moderate tension. Although she was asymptomatic, postoperative transesophageal echocardiography (TEE) revealed an abnormal cavity, containing heterogeneous echogenesity without blood flow, in the posterior LA wall. Magnetic resonance imaging (MRI) demonstrated a mass without significant enhancement. It was considered to be an intramural hematoma, and the diagnosis of LA dissection was made. Follow-up echocardiography showed disappearance of the dissected lumen without surgical intervention. Both TEE and MRI are useful for the correct diagnosis of an LA dissection; and surgical intervention, entry closure or internal drainage, may not always be necessary in the absence of a hemodynamic compromise with an LA dissection.
A 75-year-old woman, who had been treated for rheumatic arthritis, was transferred to our hospital because of acute abdomen and continuous fever for several weeks. She had peritonitis, and abdominal computed tomography detected a thrombus occluding the proximal superior mesenteric artery and infarctions of the kidneys and spleen. Echocardiography showed a large vegetation on the anterior leaflet of the mitral valve. The necrotic small bowel and ascending colon were resected, and mitral valve replacement was performed 5 days later. She suffered from hyperbilirubinemia and pneumonia for several weeks after the operation but recovered successfully thereafter.
We describe the case of a 69 year-old woman with a dilated ascending aorta, who presented with aortic valve regurgitation due to a quadricuspid aortic valve (QAV). There are only a few reports in the literature describing aortic replacement and subsequent aortic valve replacement for a malfunctioning QAV. We discuss the pathogenesis of the dilated ascending aorta in this patient and the indication for ascending aorta replacement in such cases.
Acute aortic occlusion is a rare but catastrophic pathology with high mortality even after revascularization. We describe four patients who underwent thrombectomy or bypass surgery for acute aortic occlusion with concomitant internal iliac artery occlusion. Two patients (82- and 75-year-old men), who had insufficient reperfusion of bilateral internal iliac arteries after treatment (thrombectomy alone and axillobifemoral bypass, respectively), died on postoperative day three of uncontrollable hyperkalemia and multiple organ failure, respectively (mortality: 50%). The third patient (74-year-old man), in whom the left internal iliac artery was reperfused after an axillobifemoral bypass, underwent right lower limb amputation but survived. The fourth patient (63-year-old man) with sufficient internal iliac artery reperfusion bilaterally after aortobifemoral and right internal iliac artery reconstruction, had an uneventful postoperative course. Elevated creatine phosphokinase and myoglobinuria levels were observed in all four patients but were notably higher in the two patients with no reperfusion in either of the internal iliac arteries. Our results suggest that reperfusion of one or more internal iliac arteries may be a crucial factor in reducing mortality in revascularization treatment of acute aortic occlusion with concomitant internal iliac artery occlusion.
An 80-year-old woman was hospitalized in a state of shock accompanied by blood acidosis due to type A acute aortic dissection complicated by respiratory, liver, and kidney failure. A warning was given to her family that lack of intervention may possibly lead to an early death, and permission for the intervention was obtained. After undergoing a “less invasive quick replacement (LIQR),” a newly modified procedure that we had developed, the patient improved gradually, went home without any complications, and continues to be well. Emergency surgery for octogenarians remains controversial, particularly for patients with a preoperative, compassionate indication. Here, we report a survival case for an emergency operation using LIQR to treat an octogenarian diagnosed with type A acute aortic dissection complicated by multiple organs failure.
Stanford type A aortic dissection frequently deforms the aortic root and causes aortic regurgitation (AR). On the rare occasion, massive AR can occur due to circumferential intimal disruption and prolapse of the cylinder-shaped intimal flap into the left ventricle. Because of the critical, general, and hemodynamic state of such patients, surgery for this condition carries a high risk. A 62-year-old woman suffered acute chest pain and fell into cardiogenic shock. Computed tomography and transthoracic echocardiography failed to identify the etiology of this rapid hemodynamic collapse. Transesophageal echocardiography (TEE) demonstrated circumferential intimal disruption, 3 centimeters above the aortic valve annulus; a very localized aortic dissection in the proximal ascending aorta; and a to-and-fro motion of cylinder-shaped intima causing severe AR. The dissection did not affect the aorta beyond the intimal tear, and TEE was the only useful modality for the diagnosis. Emergency replacement of the ascending aorta and resuspension of the aortic valve was successfully performed. Residual AR was absent, and the postoperative course was uneventful.