Fluorodeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) have become the gold standard for staging of esophageal cancer by detecting distant metastases, but metastatic lymph nodes are often difficult to diagnose from the size and standardized uptake value (SUV). If we compare the diagnostic performance of endoscopic ultrasonography (EUS), CT, and FDG-PET in staging of esophageal cancer, EUS is the most sensitive method to identify the detection of regional lymph node metastases, whereas CT and FDG-PET are more specific tests. Combination study with CT, EUS and PETCT cannot make a precise diagnosis after neoadjuvant therapy (NAT). A precise staging might be determined by the fine needle aspiration biopsy (FNAB) under EUS and US screening in the neck and the abdomen even after NAT. Indication of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for superficial cancer is sensitive because of difficulty in T1b cancer diagnosis. Detailed examination about vessel invasion and the possibility of residual tumor with dissected specimen will offer an appropriate additional therapy. New strategy like sentinel lymph node (SLN) navigation could supply more information about lymphatic routes and metastatic nodes. SLN navigation with ESD might become a new less invasive strategy for superficial esophageal cancer.

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Purpose: To clarify whether fibulins-5 is associated with primary spontaneous pneumothorax (PSP) in young PSP patients.
Methods: Forty-six surgically resected, fresh lung specimens were used. Patients were divided into 3 groups: younger than 25 years with pneumothorax (group Y), 25 years or older with pneumothorax (group O), and without pneumothorax (group C). Chest X-ray, computed tomography data, height/width ratio (H/W) and anteroposterior/transverse diameter ratio (a/b) were measured. Elastica van Gieson staining and immunofluorescence staining for fibulin-5 were performed. Fibulin-5 mRNA expression and protein levels were measured by real-time PCR and western blotting. Direct sequences of the fibulin-5 gene in PSP patients were performed.
Results: The mean H/W ratio in group Y was significantly larger than that in the other groups (p <0.01). The mean a/b ratio in group Y was significantly smaller than that in the other groups (p = 0.02). Fibulin-5 mRNA expression was not significantly different among the groups (p = 0.64). The relative intensity of fibulin-5 protein in group Y was significantly lower than that in group O (p = 0.006), with no significant differences between groups O and C (p = 0.14).
Conclusions: We showed that fibulin-5 is reduced in patients with PSP who are younger than 25 years.

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Purpose: The objective of the present study was to evaluate the effects of inhaled tiotropium on pulmonary function and left ventricular diastolic function in chronic obstructive pulmonary disease patients ≥1 year after pulmonary resection for lung cancer.
Methods: This prospective single-arm analysis involved 21 chronic obstructive pulmonary disease patients who underwent pulmonary resection for lung cancer at least one year earlier. Blood pressures, heart rate, spirometry, transthoracic echocardiography including tissue Doppler imaging, and quality of life were evaluated prior to and after 3 months of inhaled tiotropium treatment. B-type natriuretic peptide, white blood cell counts, and C-reactive protein levels before and after inhaled tiotropium treatment were also examined.
Results: There were no significant differences between before and after treatment in forced vital capacity and left ventricular ejection fraction. Forced expiratory volume in 1 second and early transmitral velocity/tissue Doppler mitral annular early diastolic velocity values improved from 1.60 ± 0.5 L and 8.97 ± 1.6, respectively, before treatment, to 1.84 ± 0.5 L and 7.59 ± 1.4, respectively, 3 months after treatment (P <0.001).
Conclusion: Treatment with inhaled tiotropium may be effective in improving not only pulmonary function but also left ventricular diastolic function of patients with chronic obstructive pulmonary disease in the chronic phase after pulmonary resection.

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Purpose: It has been reported that Integran^®, a sheet-type absorbable topical collagen hemostat, is feasible for preventing pulmonary fistula after lung surgery. The most favorable aspect of Integran^® is that it contains no blood products. However, the microscopic findings of post-surgery application of Integran^® to the lung are not known. We identified 2 such cases of Integran^® application, which were carried out a few years earlier, and described the microscopic findings.
Method: In case 1, a 53-year-old man underwent video-assisted left upper lobectomy for primary lung cancer. Integran^® was applied to the left lower lobe. Completion left pneumonectomy was performed after 2 years and 1 month due to recurrence. In case 2, a 77-year-old woman underwent video-assisted right middle lobectomy for primary lung cancer. Integran^® was applied to the right upper lobe. Completion right upper lobectomy was performed after 1 year and 8 months due to recurrence.
Results: The repaired visceral pleura of the 2 patients were covered with proliferated collagen fibers. However, there was little infiltration of inflammatory cells and fibroblasts.
Conclusion: The microscopic findings revealed that the ability of Integran^® to generate inflammation or adhesion is weak, but it has the ability to repair damaged visceral pleura.

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Background: The relation between infective endocarditis (IE) and renal insufficiency is uncertain. The aim of this study was to investigate active IE with renal insufficiency in cardiac surgery.
Patients and Methods: A retrospective record review was conducted of all cases with IE from January 1998 to July 2009. We identified 38 patients who had undergone surgical intervention (25 males and 13 females, mean age 57.3 ± 15.2 years, range 23–83 years) of IE as defined by the modified Duke criteria. Indications for surgical intervention included new, severe valvular regurgitation with heart failure, intracardiac abscesses, and recurrent embolic events. All patients were divided two groups; one group comprised patients without renal insufficiency (group N, n = 28), the other, those with renal insufficiency (group R, n = 10).
Results: Mean age of patients in group R was larger than that in of group N (66.3 ± 10.6 vs. 54.1 ± 15.4 years, p = 0.0268), and mean hemoglobin in group R than in group N (8.4 ± 0.9 vs. 10.3 ± 2.5 g/dl, p = 0.0215). In the early outcome, hospital death was greater in group R than in group N (20.0% vs. 0.0%, p = 0.0143). The 8-year survival was significantly worse in group R than in group N (50.0% vs. 96.4%, log rank test: p = 0.0042). Moreover, the 8-year actuarial freedom from cardiac events was significantly worse in group R than in group N (0.0% vs. 60.3%, log rank test: p = 0.0003), too. Renal insufficiency predicted an increase in long-term mortality (OR 12.104, 95%CI 1.349–108.641, p = 0.0259) and morbidity (OR 10.540, 95%CI 2.173–51.129, p = 0.0035).
Conclusions: In IE, renal insufficiency may allow for risk stratification of patients undergoing surgical intervention.

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Objectives: To compare the long-term outcomes of endovascular repair (EVAR) versus open repair for abdominal aortic aneurysm (AAA).
Design: We retrospectively reviewed consecutive AAA patients treated with EVAR (n = 89) or open repair (n = 136) from January 1998 to December 2008.
Results: More patients in the open repair group had a longer duration of hospital stay. The operation time was significantly longer in open surgery than in EVAR (p <0.001), and the percentage of patients requiring a transfusion was higher in the open repair group than in EVAR. Patients in the open repair group had a higher incidence of cardiac insufficiency after surgery than did those in the EVAR group. Kaplan-Meier analysis indicated that the proportion of patients without complications in the EVAR group was significantly less than that in the open repair group (68.1% vs. 91.1%; p <0.0001), and the long-term survival rate in EVAR group was similar to open surgery group (87.5% vs. 91.1%; p = 0.555). Thrombosis was found inside of the aneurysm; postoperative complications in the EVAR group included ischemic legs, graft stenosis, and endoleaks that required further endoluminal treatment.
Conclusions: Endovascular repair of abdominal aortic aneurysm causes less trauma in patients with AAAs in the short term, and patients treated with EVAR have similar survival rate with open repair in the long term, but have postoperative complications requiring further interventional treatment.

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Objective: To compare the effect of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with solely CEA.
Methods: During a five-year period ending December 2009, 25 consecutive patients received concomitant CEA and CABG, whereas, 62 consecutive patients underwent only CEA. They were followed at the median for 64.5 months. The Kaplan-Meier method was used to evaluate the survival rate of patients in both groups.
Results: There was no significant difference in terms of age, proportion of gender, risk factors of coronary artery disease and carotid artery stenosis. The degree of carotid artery stenosis was identical in both study groups. One patient in CEA/CABG group had 60% stenosis of carotid artery with ulcerative plaque. There was no early death in the short postoperative period. Restenosis was found on ultrasonography in 4 patients in the CEA/CABG group, and 12 patients in the CEA group; no statistical difference was found between both groups (P = 0.952). The intubation time, ICU stay, and hospital stay in CEA/CABG group were longer than in solely CEA group (P <0.001). The median duration of follow–up was 64.5 months (IQR 24–84 months). The survival rate was 88 %(22/25) in CEA/CABG group and 80.6 %(50/62) in CEA group, product-limit analysis showed that there was no significant difference in survival rates between two groups (P >0.05).
Conclusion: concomitant carotid endarterectomy and CABG can be safely performed, it could prevent stroke and would not increase the overall risk of surgery.

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A 5-year-old girl presented to our hospital with prolonged pneumonic symptoms over 3 months. After a complete work-up, she was diagnosed with endobronchial mucoepidermoid carcinoma and treated with a left upper sleeve lobectomy. The patient is cured and doing well, 8 months after the surgical resection.

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Most solitary extramedullary plasmacytomas are plasma cell tumors that tend to develop in mucosa-associated lymphoid tissues including the upper respiratory tract. We present a 43-year-old patient who was diagnosed with a solitary plasmacytoma in the lung. Primary plasmacytoma of the lung is exceedingly rare, and the treatment is surgical excision. This malignancy advances to multiple myeloma in a minority of patients. Multiple myeloma is a plasma cell malignancy that typically presents in the bone marrow.

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Wedge resection for tissue diagnosis of indeterminate lung tumors that is strongly suspected of being lung cancer, is sometimes difficult, and lobectomy, followed by a thorough pathological examination, is required. In the present report, four cases are presented, and the following indications, which have never been discussed before, are recommended for lobectomy without a pre-resectional diagnosis. First, where larger tumors are involved, and lobectomy is expected to result in a more favorable patient status and second, where the lesions are deeply located near major pulmonary vessels, or the patient is not a candidate for wedge resection or segmental resection. In each case, tolerance to surgery and detailed, informed consent for potentially complete resection are mandatory.

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Here, we describe our experience in treating a patient with mediastinal hemangioma, a rare neoplasm. An abnormal shadow was noted in the thoracic region of a 54-year-old woman at a health checkup, and she was referred to our hospital. A neurogenic tumor was suspected based on the findings of the chest X-ray and computed tomography scan. Thoracoscopic tumorectomy was performed. The tumor surface was smooth with a reddish-dark reddish color, and capillary blood vessels showed marked growth around the tumor. The tumor was composed of medium or large blood vessels with a relatively thick vascular wall containing smooth muscle. On immunostaining, anti-CD34 antibody and Factor VIII were positive and D2-40 was negative. Based on these findings, the tumor was diagnosed as mediastinal venous hemangioma.

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Solitary fibrous tumor of the pleura (SFTP) is a rare tumor especially presents malignant features. Such symptoms of hemoptysis and dyspnea were rarely seen and take 5% and 4% respectively in malignant SFTP. A 26-year-old Chinese man, presenting with hemoptysis in the emergency room, was hospitalized because of dyspnea. The X-ray examination revealed a tumor in the right chest cavity. The patient refused treatment, and the tumor grew rapidly, which complicated the symptoms of the patient. En-bloc excision of tumor plus the involved lung was performed. There was at least a 5000-ml mixture of blood and tumor tissue in the right chest cavity because of continuous bleeding, leading to a tumor capsule split. Histopathology and Immunohistochemistry identified the tumor as malignant SFTP, but CD34 was negative. In this case, the tumor grew rapidly and aggressively in two months, indicating that close follow-up and active treatment are needed.

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A 31-year-old woman was referred to our hospital due to progressive dyspnea and a family history of pulmonary embolism. Multislice computed tomography depicted massive bilateral pulmonary embolism, and transesophageal echocardiography demonstrated a serpentine structure in both atria with the appearance of a thrombus. Furthermore, a highly mobile mass trapped in her patent foramen ovale was identified. She underwent emergency cardiac embolectomy and was discharged from our hospital with conventional anticoagulant therapy.

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A 60-year-old man was admitted to our hospital because of aortic stenosis with a peak pressure gradient of 61 mmHg, moderate aortic regurgitation, and a dilatation of the ascending aorta of 50 mm in diameter, which had grown 5 mm in 2 years. Because of severe aortic stenosis with a bicuspid valve and fast progression of the ascending aorta in size, replacements of both the aortic valve and the ascending aorta were planned.
He had experienced severe acute renal failure with hemolysis because of cold agglutinin one year before the operation. The hemoglobin had decreased to 4.3 g/dL during hemolytic attack. His titer of cold agglutinin was extremely high. The titer of cold agglutinin has kept above than 1:131072 at 4 degree Celsius. It once increased to 1:524288.
Both the replacement of the aortic valve and the ascending aorta under normothermic cardiopulmonary bypass using intermittent warm blood cardioplegia were completed uneventfully. He was discharged from the hospital on postoperative day 11.

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A 62-year-old man with a medical history of aortic valve replacement was referred to our hospital with high-grade fever. Blood culture was positive for Streptococcus dysgalactiae, and the echocardiogram showed edematous aortic annulus, suggesting a perivalvular abscess. Treatment with antibiotics was started, which showed progressive improvement. The echocardiogram at 2 weeks after admission showed progression of the perivalvular abscess, resulting in the formation of a perivalvular pseudoaneruysm, which revealed rapid enlargement. The patient underwent surgical resection of a 20-mm pseudoaneurysm, originating from the right and left coronary cusp. Complete resection of the infective tissue was performed, and an aortic root replacement was done. This case highlights that a frequent follow-up should be performed in case of perivalvular abscess, because of the risk of pseudoaneurysm formation, which may cause a life-threatening outcome.

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Spontaneous ductal aneurysm is rare in adults, although it is diagnosed sporadically, even in the elderly. Commonly, patients with a ductal aneurysm undergo an aneurysmectomy followed by patch-plasty through a lateral thoracotomy. However in older patients, more extensive surgery is often required due to more developed atherosclerotic lesions, requiring total arch replacement. Here, we describe the repair of a ductal aneurysm through a hemi-clamshell incision in an elderly patient. This method enabled excellent exposure of the entire aneurysm and, most importantly, adaptability in performing either an aneurysmectomy followed by patch closure, or total aortic arch replacement, dependent on the extent of the atherosclerotic disease once surgically exposed.

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Delayed neurologic deficits, paraplegia and paraparesis, are devastating complications after repair of a descending thoracic and thoracoabdominal aortic aneurysm (TAAA). A treatment protocol has not been established, although strategies such as cerebrospinal fluid (CSF) drainage, maintaining blood pressure and medication have been described. Cerebrospinal drain status /oxygen delivery/patient status (COPS) therapy for delayed neurological deficit can improve spinal cord ischemia through reducing intraspinal pressure, improving oxygen delivery and maintaining high blood pressure. We describe one patient (Case 1), in whom descending thoracic and abdominal aortic aneurysms were treated by endovascular aortic repair, and another (Case 2) with Crawford type II TAAA, who developed delayed neurological deficits that were treated with immediate COPS therapy (Modified Tarlov scale; Case 1, improved from 2 to 4; Case 2, from 0 to 4). These findings indicate the benefit of COPS for treating delayed neurological deficits after descending thoracic and TAAA.

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We report a rare case of failed depiction of a patent right internal thoracic artery (RITA) to left anterior descending artery (LAD) bypass on 64-slice multidetector row computed tomographic (MDCT) angiography due to the presence of a large lateral costal artery. A 66-year-old male with acute coronary syndrome due to triple vessel disease underwent urgent coronary artery bypass grafting, in which bilateral ITA and saphenous vein grafts were used. Postoperative MDCT angiography showed an occluded RITA-LAD bypass, which was eventually shown to be patent by angiography. Angiography also revealed a large lateral costal artery that was considered to affect the flow to the LAD. Thus, coil embolization of the branch was attempted. However, it was abandoned because the patient suffered from severe back and intercostal pain during balloon occlusion of the lateral costal artery. Postoperative MDCT angiography is not always accurate for the assessment of graft patency in patients with large ITA side branches. In addition, embolization is not always possible because occlusion of this large branch may cause severe pain when its size becomes quite large.

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Purpose: One current method of anastomosis in aortic dissection type A is the adventitial inversion technique. To improve hemostasis at the anastomotic site, we have developed a novel technique for distal anastomosis involving adventitial inversion employing graft telescopic insertion.
Methods: The adventitia was inverted into the aortic lumen and the anastomosis with a Dacron tube-graft was made in a telescopic method, covering the inverted adventitia.
Results: Five patients have undergone emergency ascending aortic replacement for aortic dissection by one surgeon using this technique. There have been no reoperations for bleeding or false aneurysm.
Conclusion: Complete coverage of the inverted adventitia eliminated the potential risk of thrombus formation. Graft telescopic insertion lead to complete hemostasis.

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Although fewer lymph nodes are dissected with video-assisted thoracic surgery than with open lobectomy, thoracoscopic lobectomy is increasingly becoming the preferred surgical approach for early-stage lung cancers. The endoscopic surgical spacer SECUREA™ is a medical device that has been effectively employed in laparoscopic surgery, but no study has evaluated its efficacy in thoracoscopic surgery. In this report, we demonstrate the utility of SECUREA for complete thoracoscopic mediastinal lymph node dissection in patients with non-small cell lung cancer.

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