Purpose: Reconstruction with free jejunal graft (FJG) has been widely accepted for patients undergone pharyngo-cervical esophageal resection. Those patients often suffer variety of complications regarding postoperative peros function. We investigated risk factors especially focused on the development of dysphagia after FJG reconstruction. Methods: A retrospective analysis was conducted using clinical chart review of 30 consecutive patients who underwent reconstruction with a FJG after pharyngo-laryngoesophagectomy from 1995 to 2010. Mortality, morbidity, and postoperative dysphagia were investigated. Dysphagia was defi ned when the patients required enteral nutrition until later than 1 month postoperatively without any other complications, including anastomotic leakage, anastomotic stricture, FJG ischemic necrosis, and hospital death. Data on potential clinical factors were extracted and the relation of these variables to postoperative dysphagia was examined by univariate and multivariate analysis. Results: There was one patient with hospital death over total 30 patients who deceased due to fatal postoperative bleeding from arterial anastomosis of FJG. Postoperative complications occurred in 14 patients (46.7%) those included respiratory complication in 5, anastomotic leakage 3, FJG ischemic necrosis 2, paralytic ileus 2, ischemic change of tracheostomy 2, anastomotic stricture 1 and dysphagia 9. Dysphagia was the most frequent in this series. Multivariate analysis demonstrated induction radiation (≥60 Gy) was independently signifi cant factors for postoperative dysphagia. Conclusion: FJG reconstruction may be safe and functionally satisfactory surgical option after pharyngo-laryngo-esophagectomy. Postoperative dysphagia may be induced prior radiation therapy.

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Purpose: The Nuss procedure is a minimally invasive method for the correction of pectus excavatum (PE). Pleural effusion complicating following the Nuss procedure was uncommon but may be critical. We evaluated the risk factors of postoperative pleural effusion after Nuss repair. Methods: We included all patients with PE primarily corrected by Nuss procedure from July 2005 to December 2011. The clinical features, treatment and outcomes of these patients with pleural effusion were analyzed retrospectively. Results: 390 patients (338 men, 52 women) with a mean age of 23.9 years (5-44 years) were included. Postoperative pleural effusion occurred in 10 patients (2.6%). The time of occurrence of pleural effusion was on a mean of 16.6 days (8-32 days) after operation presenting with progressive dyspnea. All of these patients were adults, and 9 patients (90%) were repaired by two pectus bars (p <0.001). Six patients with massive pleural effusion received thoracocentesis (400 ml-1000 ml). All of the effusions were exudative. These patients took short-term indomethacin or steroids without removal of bars and all recovered well after a mean of 40 months (12-72 months) follow-up. Conclusions: Pleural effusion complicating after Nuss procedure was uncommon. It occurred most on adult patients with placement of double bars. Close follow-up in adults after more than one bar insertion is recommended. Administration of temporary medications of indomethacin/steroid and/or thoracocentesis could obtain a satisfying result. Early administration of indomethacin/steroid in adult patients repaired by two bars with mild pleural effusion for preventing pooling of effusion could also be considered.

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Purpose: Lung adenocarcinoma (AC) demonstrates various histological subtypes within the tumour tissue. A panel established jointly by the IASLC, ATS and ERS classifi ed invasive lung ACs based on the predominant histological subtype. We examined the distribution of tumours in lung AC patients according to histological subtype and analysed the effects of this classification on survival. Methods: The records of patients who had pulmonary resection for lung cancer between January 2000 and December 2009 were reviewed and 226 lung AC patients who fulfi lled the inclusion criteria were identified. Histological subtypes of the ACs and their ratios in the tumour tissue were determined. Tumours were classified according to the predominant histological subtype and subsequently graded. The relationship between the predominant histological subtype, grade and survival were analysed. Results: Tumours were predominantly acinar in 99 cases (43.8%), solid in 89 (39.3%), lepidic in 20 (8.8%), and papillary in 11 (4.8%), whereas 7 tumours (3%) were variants of AC. Stage significantly affected survival (p = 0.001); however, the predominant histological subtype had no significant effect. The 5-year survival rate for patients with histologically grade II tumours was 48.6%, whereas that in patients with grade III tumours was 56%. (p = 0.69). Conclusion: Invasive lung ACs may be defined by their predominant histological subtype. However, it is not yet possible to conclude that this classification is related to survival.

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Purpose: Although, endobronchial ultrasonography with a guide sheath is becoming a common procedure for the diagnosis of peripheral pulmonary lesions, there remain to be some inaccuracies in cases wherein the probe is located outside the lesion. We tested whether adding transbronchial needle aspiration through a guide sheath to the conventional technique increases efficacy for diagnosing peripheral pulmonary lesions.Methods: We performed transbronchial needle aspiration through a guide sheath for 37 subjects with peripheral pulmonary lesions between September 2012 and April 2013. The devices used were as follows (all Olympus Ltd., Tokyo, Japan): 1T-260 or LF-TP bronchoscope, K203 guide sheath kit and NA-1C-1 needle apparatus, customized by cutting the guide sheath 30 mm from the proximal end to fit well with the needle.Results: The endobronchial ultrasound probe was located within the lesion in 21 cases (56.8%) and outside in 16 cases (43.2%). Overall accuracy was 86.5 percent; 90.5% in “within” cases compared to 81.3% in “outside” cases with no significant difference (P = 0.42). Pneumothorax occurred in 2 cases and pneumonia in 1 case.Conclusion: Transbronchial needle aspiration through a guide sheath is an effective and safe diagnostic procedure for peripheral pulmonary lesions, especially when the guide sheath is outside the lesion.

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Background: Regional lung transplantation centers should be equipped with an inter-hospital transport program that can provide life-support for lung transplant candidates who develop acute respiratory failure outside the hospital. The purpose of this study was to assess the value of extracorporeal membrane oxygenation (ECMO) as a means of support during transport and as a bridge to lung transplantation for transplant candidates who develop respiratory failure outside the transplantation center.Methods: We retrospectively analyzed data from 7 patients who developed acute lung failure during treatment of end-stage lung diseases at other hospitals and for whom inter-hospital transport to the lung transplantation center at our hospital was requested between December 2011 and June 2013.Results: All 7 patients were treated with ECMO via a Terumo Emergency Bypass System^® (EBS^®) during transport, and all were transported without incident. There were no adverse events related to ECMO. All patients maintained stable vital signs during transport. Four patients received lung transplant within 10.5 ± 2.3 days (range: 7 to 12 days) after transport, 1 patient was weaned from ECMO without transplant, and 2 patients died with multi-organ failure while awaiting donor lungs.Conclusion: ECMO was useful for transfer of lung transplant candidates who developed acute respiratory failure at other institutions and as a bridge to lung transplantation. An inter-hospital transport program involving ECMO may increase the likelihood of successful transport to regional transplantation centers for lung transplantation candidates who show respiratory failure.

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Objective: The goals of this study were to establish a new model for predicting in-hospital mortality of percutaneous coronary intervention (PCI), and to compare the predictive accuracy of the new model with the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model. Methods: We retrospectively analyzed 18206 Chinese patients undergoing PCI in our hospital between January 2002 and December 2008. Univariate and multivariate logistic regression analysis were performed to determine the preoperative risk factors that predicted in-hospital mortality. The EuroSCORE model was used to predict in-hospital mortality. To improve the predictive value of the EuroSCORE, we proposed a modifi ed EuroSCORE that included some PCI-specifi c factors. Results: Multivariate logistic regression analysis indicated that left main trunk lesions, type C lesions, preoperative high-risk state, emergency PCI, and severe reduction of ejection fraction (<30%) were independent predictors of PCI mortality. Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve for the modifi ed EuroSCORE was larger than that for the EuroSCORE, however, there was no signifi cant difference between the actual mortality rate and the mortality rate predicted by the two models. The modifi ed EuroSCORE more accurately predicted the mortality rate in patients with a EuroSCORE score of 7-9 points, whereas it was no better than the standard EuroSCORE in patients with EuroSCORE scores of 1-3 or 4-6 points. Conclusion: The modifi ed EuroSCORE improves acute risk assessment in PCI patients compared with the EuroSCORE, and the mortality rate predicted by the modifi ed EuroSCORE in high-risk patients was close to the actual mortality rate.

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Objectives: Reduction of cognitive function is a possible side effect after coronary artery surgery using cardiopulmonary bypass (CPB). We investigated the effect of single versus dual antiplatelet therapy on cognitive performance in patients undergoing coronary artery bypass grafting (CABG) with CPB. Methods: 50 consecutive CABG patients with preoperative intake of aspirin were compared to 49 consecutive patients with aspirin and clopidogrel. Six neuropsychological subtests from the Syndrom Kurz Test and the Alzheimer's Disease Assessment Scale were performed preoperatively and on the third postoperative day. To assess the overall cognitive function and the degree of cognitive decline across all tests after surgery we combined the six test-scores by principal component analysis. Results: Patients had a mean age of 66.1 ± 9.3 years, received a mean of 2.8 ± 1.0 bypasses within an average of 87 ± 31 minutes on cardiopulmonary bypass. These parameters as well as the preoperative combined neurocognitive score were not significantly different between the groups. After the operation there was a significant deterioration of the combined neuropsychological score in both groups (single: preop −0.2 ± 1.5 vs. postop −1.8 ± 1.7, p = 0.000 and dual: preop 0.2 ± 1.5 vs. postop −0.5 ± 2.1, p = 0.004). However, the patients operated under dual antiplatelet therapy showed a significant less decline of overall cognitive function compared to the single antiplatelet therapy patients (dual: 0.7 ± 1.5 vs single: 1.6 ± 1.6, p = 0.004). Conclusion: Dual antiplatelet therapy has a cerebroprotective effect in patients undergoing coronary artery bypass surgery. Compared to single antiplatelet therapy it reduces an early postoperative substantial decline of neuropsychological abilities.

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Purpose: A low ratio of serum eicosapentaenoic acid to arachidonic acid (EPA/AA) has been associated with coronary artery disease. We retrospectively examined serum concentrations of polyunsaturated fatty acids in patients with arteriosclerosis obliterans (ASO) and in non-atherosclerotic patients. Methods: From April 2011 to March 2012, serum EPA/AA was retrospectively examined in 33 consecutive outpatients with ASO complicated by intermittent claudication and 21 outpatients with hypercholesterolemia without ASO as controls. The Student's t-test was used for continuous variables and Chi-square test for categorical variables, with analysis of covariance adjusting for age, sex, body mass index, smoking, alcohol, and diabetes. Results: The ASO group were significantly different with regard to mean age (71.5 vs. 63.9 year-old, p = 0.03), body mass index (21.3 vs. 24.1 kg/m², p = 0.002) and morbidity of diabetes mellitus (51.5 vs. 4.8%, p = 0.0004). Serum EPA/AA was significantly decreased in ASO (0.36 vs. 0.61, p = 0.03), when adjusted for age, sex, body mass index, smoking status and alcohol drinking, but was not statistically significant when adjusted for diabetes. Conclusion: Patients with ASO were more likely to have a low EPA/AA ratio and non- diabetic patients with ASO had a significantly reduced EPA/AA.

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Purpose: This study aimed to determine if preoperative time course changes in serum C-reactive protein (CRP) levels can predict clinical outcome of surgical intervention for active infective endocarditis. Methods: Surgically treated patients (n = 109) with active infective endocarditis were reviewed retrospectively. We divided the patients into 2 subgroups according to preoperative transition of increasing or decreasing serum CRP levels, and performed a comparative study. The increasing CRP group included 29 patients and the decreasing CRP group included 80 patients. Results: There were more patients with methicillin-resistant Staphylococcus aureus and New York Heart Association functional class IV in the increasing CRP group. Hospital mortality was signifi cantly higher in the increasing CRP group (34.5%) than that in the decreasing CRP group (5.0%) (p <0.05). In multivariate analysis, 3 signifi cant risk factors of surgical outcome were identifi ed: a tendency for increasing preoperative CRP levels (odds ratio [OR]: 18.15, 95% confi dence interval [CI]: 1.03-320.78), nosocomial infective endocarditis (OR: 18.73, 95% CI: 1.57-223.60), and dialysis (OR: 1025.46, 95% CI: 2.89-363587.12). Conclusion: The outcome of operations for patients with increasing preoperative CRP levels is poor. For treatment of active infective endocarditis, a better operative result is expected when preoperative CRP levels are decreasing.

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Purpose: Endovenous laser ablation (EVLA) for superficial venous insufficiency is traditionally performed under tumescent local anesthesia as day case surgery. The aim of this study is to evaluate the feasibility of general anesthesia in addition to tumescent anesthesia in patients undergoing EVLA.Methods: The anesthesia and clinical registration records of 341 extremities of 300 adult patients were reviewed and analyzed retrospectively. Demographic and clinical data, preoperative anesthetic evaluation data (ASA physical status, preoperative airway assessment, Mallampati score), type of supraglottic device, duration of anesthesia and surgery, any surgical and/or anesthetic complication, timing of mobilization and discharge, and postoperative course were evaluated.Results: Mean duration of operation and anesthesia was 28 (12–55) and 40 (20–65) minutes, respectively. Mobilization and discharge timing was 25 (11–45) and 139 (110–200) minutes, respectively. All patients were discharged the same day of surgery.Conclusion: The combination technique of administering general anesthesia with supraglottic device and tumescent anesthesia is a safe and effective method to reduce the patients’ pain and discomfort during the EVLT procedure within the scope of day case surgery.

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Purpose: To determine the influence of the abdominal aortic aneurysm (AAA) anatomy on the clinical outcomes after endovascular AAA repair (EVAR). Methods: Between January 2008 and December 2010, 53 patients underwent EVAR. The parameters outside of the device instructions for use (IFU) were: short neck length (<15 mm), proximal neck angulation (>60 degrees), small diameter of external iliac artery (<7 mm) and bilateral internal iliac embolization. Results: A total of 37% of these grafts were placed outside of at least one IFU parameter. The intraoperative problems encountered included one (3%) acute graft limb thrombosis, and one (3%) access vessel rupture within the IFU (w-IFU) group. One perioperative mortal case was observed in the w-IFU group due to thoracic aortic dissection. After one year follow-up, type II endoleak (EL) was recognized in 8 of 28 (29%) patients in the w-IFU group, and in 2 of 12 (17%) patients outside of the IFU (o-IFU) group. There was also no significant difference of early and mid-term outcomes between favorable neck anatomy and hostile neck anatomy (HNA). Conclusion: In our series, EVAR provided acceptable results even in the o-IFU group and HNA. This suggests that the IFU can be extended to other selected patients.

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Mediastinum is one of the place in which ectopic parathyroid adenomas can be located.Here, an ectopic mediastinal parathyroid adenoma, which was excised via parasternal videomediastinoscopy was presented. The patient with chronic renal insufficiency had increased calcium levels persistence after the surgery for cervical parathyroid adenoma.Radiologic and scintigraphic examinations revealed a focal intense nodule in anterior mediastinum. Parasternal videomediastinoscopy was performed via parasternal incision through the second intercostal space. Ex-vivo specimen radioactivity measurements and frozen examination confirmed parathyroid adenoma. Calcium levels were decreased dramatically after the operation. Parasternal videomediastinoscopy could be an alternative surgical way in anterior mediastinal small masses such as ectopic parathyroid adenoma. It is the first case in which parasternal videomediastinoscopy was used for excision of mediastinal parathyroid adenoma.

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Native lung hyperinflation (NLH) is one of the known complications after single lung transplantation (SLT). Generally, satisfactory results are achieved in patients undergoing SLT when simultaneous (or second stage) volume reduction of the contralateral native lung is performed. Contralateral native lung pneumonectomy after SLT is rarely reported. In this article, we report a case of a successful, right pneumonectomy of the native lung, 3 years after a left single lung transplant for pulmonary lymphangioleiomyomatosis (PLAM). The patient’s pulmonary function and quality of life improved significantly after a right pneumonectomy of the native lung.

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We report a successfully treated case of rapid progressive left ventricular (LV) thrombus with ischemic cardiomyopathy. Initially, the patient was scheduled to undergo only coronary artery bypass grafting. After two months, preoperative echocardiography revealed a previously undetected ball-like thrombus in the LV cavity. Surgical revascularization and thrombectomy were performed. No systemic embolism was associated with surgical manipulation during the perioperative period. Repeated preoperative evaluation for the presence of thrombus by transthoracic or transesophageal echocardiography is essential in cases of ischemic cardiomyopathy.

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Left ventricular noncompaction cardiomyopathy is a rare type of congenital cardiomyopathy characterized by prematurely arrested compaction of the endocardial and myocardial fibers and the progressive deterioration of left ventricular contractility. This entity is a genetically heterogeneous disorder and has a wide spectrum of presentation from no symptoms to critical disabling congestive heart failure, which can appear at any age. The prognosis is therefore varied. An elderly patient with left ventricular noncompaction underwent aortic valve replacement for associated aortic regurgitation.Follow-up at two years after surgery revealed an improved clinical condition and recovered cardiac function. This is the fourth known aortic valve replacement in a patient with left ventricular noncompaction.

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In spite of modern advances in medical care, the operative mortality of ruptured abdominal aortic aneurysm remains high at 40%-50%. Multiple organ failure is one of the reasons for the high mortality rates. An acute increase in intra-abdominal pressure and abdominal compartment syndrome are common causes of multiple organ failure.It is important to prevent abdominal compartment syndrome to improve the outcome of ruptured abdominal aortic aneurysm. Delayed abdominal closure is effective in preventing abdominal compartment syndrome in patients with ruptured abdominal aortic aneurysm. We successfully achieved delayed abdominal closure using the ventral hernia repair prosthesis for a ruptured abdominal aortic aneurysm, in a straightforward and rapid manner. No infection was seen, secondary closure was readily performed, and wound healing was good. We conclude that our delayed closure technique is useful for the treatment of ruptured abdominal aortic aneurysm.

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Primary large saccular aortic aneurysm with high grade stenosis of aortic arc is rare, and no standard therapy is available. We have encountered one case and successfully treated using a hybrid interventional approach. A 59-year-old woman with a 7-day history of headache, dizziness and chest pain, and a 5-year history of hypertension admitted and was diagnosed with transverse aortic aneurysm with sever aortic stenosis, the huge saccular aneurysm was located behind the transverse aortic arc. During surgery, a bypass with graft from ascending aorta to left external iliac artery was made initially in order to ensure the blood supply to the left leg, afterward, a 40 mm × 160 mm covered stent was implanted to cover the orifice of aneurysm and was used as a supporting anchorage in the descending aorta, a second covered stent (20 mm × 100 mm) was implanted to expand the stenosis of aortic arc. Follow-up at 1.5-year after surgery, the patient has been doing well without any surgical complication. A collateral pathway between internal mammary artery and inferior epigastric artery via the superior epigastric artery was found on3-dimensional reconstruction before surgery. Interruption of the compensatory arterial collateral pathway in the patient with severe stenosis of aortic arc should be prevented if possible in order to ensure the satisfactory perfusion of the lower limbs of the body.In conclusion, a patient with transverse aortic aneurysm accompanied with severe aortic stenosis can be treated by hybrid surgery.

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