Purpose: The 2-[F-18]-Fluoro-2-deoxy-D-glucose (FDG) uptake in positron emission tomography (PET) and serum neutrophil/lymphocyte ratio (NLR) are recently noteworthy prognostic factors. We studied the prognostic factor to predict early recurrence after curative resection for pulmonary adenocarcinoma including FDG uptake and NLR.
Methods: We performed a retrospective review of 23 patients who underwent a complete resection for pulmonary adenocarcinoma. The patients were divided into 2 groups: 19 patients in the disease-free group, and 4 patients in the recurrent group. Clinical and pathological factors concerning the recurrence within 1 year of surgery were analyzed between two groups.
Results: No significant differences between the recurrent group and disease-free group was seen in age, gender, CEA, NLR, CRP, pathological stage, pleural invasion, pathological grading, Ki-67 expression, venous invasion and lymphatic invasion. The SUVmax was significantly elevated in the recurrent group (12.5 ± 2.01 vs. 5.70 ± 3.97, p = 0.0094). Tumor size was significantly larger in the recurrent group (5.58 ± 0.71 vs. 3.62 ± 1.33 cm, p = 0.0058). The first, recurrent sites in 4 patients were brain, in 3 patients; and lung, in 1 patient.
Conclusion: Both tumor size and SUVmax are possible predictors of early recurrence after curative resection in patients with pulmonary adenocarcinoma. Although it is impossible to determine the SUVmax as an independent prognostic factor, the SUVmax may be one of the predictors of early hematogenous recurrence in surgically treated pulmonary adenocarcinoma.

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Purpose: The number of patients with traumatic and iatrogenic tracheobronchial injuries is increasing. Early diagnosis, prompt establishment of a secure airway, and appropriate management could prevent sequelae and lead to a good outcome.
Methods: Between “1994–2007”, 35 patients with major airways trauma were managed. This descriptive and retrospective study evaluates clinical findings, diagnostic approaches, initial managements, definitive surgical or nonsurgical treatments and follow-up results. SPSS was used for descriptive outcomes.
Results: There were 27 males (77%) and 8 females, with a mean age of 28.2. There were 16 blunt, 11 penetrating and 8 iatrogenic traumas, at the level of the larynx in 1, larynx and hypopharynx in 3, laryngotracheal in 12, tracheal in 13, tracheobronchial in 1, and main bronchi in 5 patients. Fourteen patients (40%) were initially managed, and 21 patients were referred to us after their initial managements at outside hospitals. There were 7 complications (20%); one resulted in mortality (2.9%). The overall final results were good in 57.1%, acceptable in 31.4% and poor in 5.7% of patients, (mean follow-up time, 58.2 months). The respiratory status and the phonation looked better in the initially managed than the delayed managed group.
Conclusion: We recommend that, patients only become respiratory stable with minimum intervention and then be referred to centers with sufficient experience in airway surgery.

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Objective: It is not clear whether surgical ventricular restoration (SVR) or procedures approaching mitral complex for controlling functional mitral regurgitation (MR) affect the regional left ventricular wall function. The purpose of the present study was to evaluate the regional LV function after SVR using overlapping left ventriculoplasty (OLVP) using quantitative gated myocardial perfusion SPECT (QGS).
Patients and Method: Forty-one heart failure patients, including those with ischemic cardiomyopathy (ICM) (n = 25) and non-ICM (NICM) (n = 16), underwent SVR and/or papillary muscle approximation (PMA). The rest myocardial perfusion SPECT were performed before and early after operation (mean 25.8 ± 10.6 days). These patients were divided into 4 groups based on the surgical procedures (SVR and/or PMA) and etiology of patients (ICM or NICM) as follows: SVR (with or without PMA) of ICM, SVR of NICM, PMA of ICM and PMA of NICM groups. The regional wall thickening was compared before and after the operation between the four groups.
Results: NYHA functional classes were improved after the operation in all four groups. MR grade was also improved in three groups other than SVR of the ICM group. The left ventricular basal wall thickening was improved postoperatively in following three groups (SVR of ICM: 12.7 ± 3.8% to 16.5 ± 4.6% p <0.05, PMA of ICM: 11.1 ± 4.3% to 14.9 ± 4.8% p <0.05, SVR of NICM: 5.8 ± 6.6% to 12.3 ± 6.4% p <0.05), whereas PMA of the NICM group did not show an improvement. Wall thickening in the middle and distal levels was not improved in all groups.
Conclusion: OLVP improved NYHA functional classes, and also improved the regional wall function at the basal level of the left ventricle. In contrast, lone PMA did not improve or impair the regional wall function at any of the levels.

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Introduction: We investigated the validation of the seventh edition of the TNM staging (2009) system for lung cancer, retrospectively.
Methods: From January 1990 to March 2004, 1629 patients who underwent lung resection with systemic lymph node dissection for non-small cell lung cancer at Nippon Medical School and Saitama Cancer Center were included. The overall survivals after surgery by each pathological stage according to the 1997 and 2009 systems were statistically analyzed using Kaplan-Meier estimated survival curves, and the significance of the difference was analyzed by the log-rank test.
Results: The 2009 system had significant prognostic distinction between each T descriptor except for T2a and T2b, and between each M descriptor. The 2009 system had better prognostic distinction between each pathological stage except for stages IB and IIA, and stages IIIB and IV. In the simulation, we unified T2a and T2b tumors into T2 tumors, and T2bN0M0 and T2bN1M0 were moved to stages IB and IIA, respectively. This proposed system had significant prognostic distinction between the proposed IB, IIA, and IIB stages.
Conclusions: The 2009 system provides better patient selection for surgery and prognostic distinction between each stage except for stages IB and IIA, and stages IIIB and IV, compared with the 1997 system. Unification of T2a and T2b tumors to T2 tumors can improve prognostic distinction between stages IB and IIA.

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Objective: Acute myocardial infarction (AMI) complicated by cardiogenic shock and left main coronary artery disease (left main shock syndrome) shows high morbidity, and whether early coronary artery bypass grafting (CABG) improves the clinical outcome remains unclear.
Methods: Six consecutive patients (mean age, 61.6 years) with MI complicated by left main shock syndrome underwent emergency CABG. Patients were divided into 2 groups according to the time from MI to reperfusion; within 8 hours in 3 patients and beyond 8 hours in the remaining. Average postoperative peak creatinine kinase (CK) and creatinine kinasemyosin band (CK-MB) levels were recorded, and the ejection fraction (EF) was measured with ultrasound cardiography.
Results: Significant differences in postoperative EF and CPK-MB were observed between the 2 groups. The 30-day survival rate was 100%. Five patients left the hospital alive, while 1 died on postoperative day 78.
Conclusions: AMI complicated by cardiogenic shock and left main coronary artery disease can be effectively treated with emergency CABG, with acceptable mortality and morbidity. Emergency CABG for MIs within 8 hours can improve survival in patients with left main shock syndrome.

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Lymphangioma is a well-known benign tumor and its cystic abnormalities of the lymph vessels are predominantly congenital. Cystic lymphangioma usually occurs in the neck, axillary region, and rarely in the mediastinum, which frequently occurs in children and young adults. A 20-year-old woman had symptoms of palpitation, cough, and dyspnea during the recent 1 month. Both chest comuted tomography and magnetic resonance imaging of the chest revealed a well-defined, 13 × 10-cm cystic lesion in the anterior mediastinum. The patient underwent bilateral video-assisted thoracoscopic excision of the cyst and lymphangioma was confirmed based on histopathologic examination. Here, we report a rare case of isolated mediastinal cystic lymphangioma that was successfully excised using a minimally invasive technique.

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A 78-year-old man underwent right lower lobectomy for lung cancer. Histopathological examination led to the diagnosis of adenosquamous cell carcinoma. The background lung adjacent to the pleura showed idiopathic pulmonary fibrosis of microscopic usual interstitial pneumonia pattern, although preoperative computed tomography showed no apparent findings of interstitial pneumonia. The patient showed an acute exacerbation of idiopathic pulmonary fibrosis on the third postoperative day. We herein report a case of acute exacerbation of idiopathic pulmonary fibrosis of microscopic usual interstitial pneumonia pattern after lung cancer surgery.

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Bullous emphysema is an important risk factor for lung cancer. Here, we report the case of a 56-year-old man who underwent surgical treatment for primary lung cancer arising from the wall of a bulla. Chest computed tomography (CT) had revealed a nodule arising from the bulla wall. This nodule showed positive uptake of ¹⁸fluorodeoxyglucose (FDG) during positron emission tomography (PET)-CT. However, repeat CT performed after 2 months showed a spontaneous decrease in the tumor size. Exploratory resection revealed non-small cell lung cancer, which was confirmed by the findings of intraoperative frozen-section analysis; therefore, right upper lobectomy and mediastinal lymph node dissection were performed. The postoperative, pathological diagnosis was squamous cell carcinoma arising from the wall of a bulla. From this case, we infer that lung cancer arising from the wall of a bulla may spontaneously regress, and FDG/PET is a useful tool to diagnose lung tumor in patients with pulmonary bullous disease.

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Castleman’s disease (CD) is a rare disease with unknown aetiology. It is characterised by benign lymph node hyperplasia that may involve all lymph nodes. The most common locations are the mediastinum and abdomen. CD arising from intrapulmonary lymph nodes has been reported in five cases, in the English language literature to date. Tumours in these patients are usually resected during lung surgery. An asymptomatic 29-year-old male patient was evaluated due to a mass lesion with a diameter of 55 mm located in the infrahilar region of the right lung with a high degree of contrast enhancement on thoracic computed tomography (CT). Vascularity of this central lesion was excluded by pulmonary angiography. Thoracotomy was performed due to the inability to obtain a diagnosis with percutaneous fine needle aspiration biopsies. A frozen section examination of the mass revealed a benign lesion, arising from the intrapulmonary lymph nodes and protruding to the lower-lobe parenchyma. The mass was then extracted from the parenchyma. After histopathological evaluation of the mass, CD involving the lymph nodes was diagnosed. CD rarely involves the intrapulmonary lymph nodes. Diagnosis is difficult in these patients, and thoracotomy may be required. After obtaining benign results by mass sampling, limited resection of these masses, while sparing the lung parenchyma, may be possible.

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Abnormal nodules were found in the left lung of a 52-year-old woman in segments 6 and 10 on a chest CT. These nodules showed no changes for 18 months, and we discontinued follow-up. Almost 5 years later, an abnormal shadow was found in her left lower lung field on a medical check-up chest X-ray. Chest CT revealed that the left segments 6 and 10 nodules had grown. We diagnosed these lesions as synchronous double primary lung cancers in the same lobe based on the disease history and performed a left lower lobectomy and lymph node dissection. Pathological examination of both tumors revealed adenocarcinoma of a mixed subtype with papillary and bronchioloalveolar carcinoma. Epidermal growth factor receptor gene mutations were examined, and the 2 lesions shared an L858R mutation. Although we expected EGFR gene mutation analysis would help us distinguish the 2 lesions from each other, it was of little help. Disease history can be more important in evaluating multiple pulmonary cancers.

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We present a 12-year-old girl with a teratoma with malignant transformation (TMT) of the mediastinum. Computed tomography showed a cystic mass (5.0 cm × 4.0 cm) with a thick solid portion, in the anterior mediastinum. Six months later, the solid portion of the mass had enlarged, and surgical resection was performed. The resected tumor was 7.0 × 5.0 × 4.0 cm in size. The cystic portion was a mature teratoma, and the solid portion predominantly comprised a viable embryonal rhabdomyosarcoma. There were no immature teratomatous elements or other germ-cell components. The histopathologic diagnosis was a mature teratoma with embryonal rhabdomyosarcoma, a so-called TMT. The tumor recurred, despite adjuvant chemotherapy. The patient died of progressive disease 16 months postoperatively. To the best of our knowledge, no naturally occurring TMT of the mediastinum has previously been reported in a child. Surgical resection at an early stage is necessary.

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We report a case of 77-year-old woman suffering from breathlessness on exertion and dry cough. Chest computed tomography (CT) showed diffuse ground-glass shadows. A video-assisted thoracoscopic lung biopsy resulted in the diagnosis of diffuse large B-cell lymphoma (DLBCL). Gene rearrangement analysis using polymerase chain reaction (PCR) technique was performed on the cells in bronchoalveolar lavage (BAL) fluid, and showed the clonality of the immunoglobulin heavy chain (IgH) gene, supporting the diagnosis. DLBCL should be considered in the differential diagnosis of diffuse ground-glass shadows in the chest CT, and gene rearrangement analysis may have an impact on the diagnosis of pulmonary DLBCL.

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Transdiaphragmatic off-pump coronary artery bypass grafting (OPCAB) to the right coronary artery, is an effective way to reduce the risks of second bypass surgery as well as the risk of graft injury after coronary artery bypass grafting (CABG). We report two cases of successful OPCAB as re-do surgery in which the right gastroepiploic artery (RGEA) was grafted to the right coronary artery. The first case was a 58-year-old woman, who underwent CABG 10 years ago. OPCAB (RGEA to right coronary artery) was performed since myocardial perfusion scintigraphy revealed ischemia in the inferior wall. The second case was a 67-year-old man who had hypertension, hyperlipidemia, peripheral arterial disease, and was undergoing dialysis (for 6 years). Six years previously, he developed a mycotic aneurysm of the right coronary artery and underwent open-heart surgery. He often had episodes of angina at night or during dialysis, and then developed congestive heart failure and was hospitalized. Since ischemia was considered to be in the inferior wall, the RGEA was grafted to the right coronary artery.

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A 54-year-old man presented with neck pain and hoarseness. Angiography showed a rare right subclavian artery aneurysm, enlargement of the ascending aortic aneurysm, and axillary artery stenosis. These aneurysms would normally be treated with end-to-end anastomosis, but due to the complexity of the lesion in this case, we performed more extensive surgery. This consisted of successful reconstruction of the subclavian artery and replacement of the ascending aorta and aortic arch.

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Twelve years after receiving a renal transplant, a 50-year-old woman developed asthmatic symptoms. Chest CT revealed a descending thoracic aortic aneurysm. She had undergone percutaneous coronary intervention to treat the left anterior descending artery 10 years earlier. Coronary artery angiography revealed restenosis of the left anterior descending artery (99%, #6 in-stent). Because cardiopulmonary bypass may cause problems for transplanted kidney, we performed off-pump coronary artery bypass grafting (left internal thoracic artery to left anterior descending artery) and thoracic endovascular graft placement to treat the aortic aneurysm. Considering that the artery of the transplanted kidney was attached to the right iliac artery, and then the left common femoral artery was selected as the access root for GORE TAG^® endografts (34 × 200 and 34 × 150 mm) (stentgrafts were deployed for the descending aortic artery). Postoperative angiography showed a patent bypass graft. Postoperative CT confirmed the absence of endoleaks. The postoperative course was uneventful, and she was discharged without complications. Ischemic heart disease and descending thoracic aortic aneurysm in recipients of kidney transplants can be treated using off-pump coronary bypass grafting and thoracic endovascular graft placement. The transplanted kidney was protected without using cardiopulmonary bypass (CPB).

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The indication for aortic valve replacement (AVR) combined left ventricular (LV) plasty in the patient with aortic valve stenosis (AS) complicated by ischemic heart disease is controversial. We describe a case of AS with ischemic heart disease of a patient who underwent a successful surgical treatment, AVR combined with the endoventricular patch technique. The patient was an 82-year-old woman who suffered from heart failure, New York Heart Association (NYHA) class III. The heart failure derived from AS and ischemic heart disease with severely compromised LV function. She underwent AVR combined with the endoventricular patch technique and the postoperative course was uneventful. She has been well with NYHA class I for about 5 years after the operation without heart failure.

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We report our experience of long-term extracorporeal membrane oxygenator (ECMO) support to resuscitate a 62-year-old man who had critical three-vessel disease of coronary artery complicating intractable hibernating myocardium (HM) and sudden cardiogenic shock. Intra-aortic balloon pump and ECMO were deployed to restore the circulatory support while emergent revascularization surgery was performed.
The patient was weaned from ECMO successfully after 15 days of support and discharged with recovered left ventricular function. ECMO is effective in resuscitation of patients with cardiogenic shock and HM. To our knowledge the present case necessitated the longest term of ECMO support to get rid of HM.

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Open heart operations for patients with myelodysplastic syndrome (MDS) are associated with infective and bleeding complications. We report a 67-year-old woman with rheumatic, severe mitral regurgitation and mitral stenosis associated with MDS who underwent a mitral valve (MV) repair. Commissurotomy was performed in the anterior commissure. Autologous pericardial patch treated with glutaraldehyde solution was prepared. The anterior leaflet was completely detached from the posterior to the anterior commissure. The anterior leaflet was augmented by autologous pericardial patch treated with glutaraldehyde solution and three pairs of artificial chordae were implanted. Postoperative transesophageal echocardiography showed an increase in the MV orifice and less than trivial mitral regurgitation. Two years after the operation, the patient has normal sinus rhythm with no deterioration of the MV lesion by transthoracic echocardiography. Although the feasibility of MV repair is low in patients with restrictive pathology due to rheumatic disease, MV repair may be preferred in patients with MDS.

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A 71-year-old woman with idiopathic thrombocytopenic purpura (ITP), who had been treated with steroid and cyclosporine, was admitted in an emergency with fever and dyspnea. The diagnosis was mitral regurgitation due ton infective endocarditis. Although she received treatments for infection and cardiac failure, the cardiac failure could not be controlled. After high-dose γ-globulin therapy, an emergency operation was performed during the active phase of infective endocarditis. Rapid platelet transfusion was administered after weaning from extracorporeal circulation. She recovered and was discharged without postoperative bleeding and re-infection.
The treatment course of elective cardiac surgery complicated with ITP has been established, but the course of emergency surgery has not been established because of the small number of cases reported. Since few patients have undergone emergency surgery for active infective endocarditis, we had difficulty in deciding the time of surgery and treatment for increasing the number of platelets before surgery, it was considered that the case provided us with useful suggestion for the future treatment for urgent surgery complicated with ITP.

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Surgeons should be aware of diaphragmatic hernia in obese patients who have undergone coronary artery bypass grafting (CABG) using a gastroepiploic artery graft (GEA), even if the antegastric route is utilized.
We report a case of diaphragmatic hernia, which occurred 88 months after initial CABG. A 64-year-old obese man underwent surgical repair of a diaphragmatic hernia. At initial surgery, the diaphragm was incised vertically and re-sutured, leaving a route for GEA graft. Both the stomach and the lateral segment of the liver were dislocated in the pericardial space. The diaphragmatic defect was closed with a polytetrafluoroethylene patch.

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Early diagnosis and treatment of prosthetic valve endocarditis (PVE) is important because it has a high mortality rate. We report a case of PVE which was difficult to diagnose. A 36-year-old man, who had undergone an aortic valve replacement (AVR) 7 years prior, was hospitalized with a high fever of unknown origin. We could not detect a stuck valve, vegetations or abscesses using echocardiography, and the peak aortic transvalvular pressure gradient had increased to 81 mmHg. We suspected PVE and initiated intravenous antibiotic therapy immediately. On day 5, echocardiography demonstrated an abnormal shadow directly under the prosthesis, and we definitively diagnosed PVE and performed an operation. Intraoperatively, the prosthesis was not vegetative, but the left ventricular outflow tract was filled with vegetation that was nearly obstructing it. After dissecting the infectious focus, we performed a re-AVR. Postoperative echocardiography showed that the peak left ventricular aortic pressure gradient decreased to 30 mmHg. Obstructive vegetation is difficult to diagnose by preoperative echocardiography.

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Purpose: In the case of an acute aortic dissection, a surgical aortic procedure is usually the priority in order to restore the perfusion of vital organs. Afterwards, associated ischemic abdominal visceral lesions can be resected. For particular patients, it could be highly beneficial to perform the abdominal surgery before surgically addressing the aorta. The aim of this paper is to contribute to the therapeutic choice in cases of acute aortic dissection with acute abdomen.
Case report: The case is reported of a 38-year-old patient, affected by an acute aortic dissection (Stanford type A) and peritonitis.
Suspecting the necessity for a complex combined surgical procedure, the patient underwent emergency diagnostic laparoscopy, which showed an infarctual necrosis of the distal ileum and right colon. Therefore, he immediately underwent a wide right hemicolectomy. Afterwards, an ascending aortic substitution was performed.
The patient was discharged on the 15th post-operative day, and he is doing well, 1 year and 3 months after the operation.
Conclusion: In the case of an acute aortic dissection with acute abdomen, emergency laparoscopy is a precious surgical technique to identify criteria that can lead to therapeutic decisions, including timing.

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