The safety and efficacy of thoracoscopic and robot-assisted lobectomies for primary lung cancer were reviewed in the literature. Thoracoscopic surgery is less invasive compared to thoracotomy, and it has been reported to be superior with regard to the outcome. In addition, the operability of a surgical robot (da Vinci) is favorable and supplements the disadvantages of conventional endoscopic surgery. Robot-assisted lobectomy has been reported to be comparable to thoracoscopic surgery with regard to the safety and efficacy based on analysis of perioperative results and superior with regard to the operability and length of the learning curve. However, a high cost and a long operative time are of concern. Since robot-assisted surgery has been performed only in early cases, the continuation of a comparative investigation may be necessary.

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The lung is one of the most common targets of metastases from gastrointestinal (GI) cancers. Surgical treatment (i.e., metastasectomy) is an accepted therapeutic option for pulmonary metastases from GI cancers. However, surgery may be contraindicated in advanced stages of cancer, compromised lung function, and/or comorbidities. This issue has prompted the search for innovative and less invasive ways of treating pulmonary metastases. Image-guided radiofrequency ablation (RFA) has attracted great interest as a minimally invasive approach against intrathoracic malignancies. In this technique, radiofrequency energy is applied via a needle electrode inserted into the target tissue. As the cells are agitated by the applied energy, they release heat, causing denaturation and cell death. Recently, this technique has been used on patients with pulmonary metastatic disease arising from GI cancers such as colorectal cancer, esophageal cancer, and hepatocellular carcinoma, as well as on patients with primary lung cancer. The present review updates the clinical outcomes and advances in RFA therapy of lung metastases from GI cancers.

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Background: There are many causes of mediastinal and hilar lymphadenopathy, such as neoplasms, granulomatous diseases, infections and reactive hyperplasia. Nowadays, the popularity of endobronchial ultrasound-guided transbronchial needle aspiration (EBUSTBNA) is increasing in the diagnosis of mediastinal and hilar lymphadenopathy. We aimed to investigate the diagnostic value of EBUS-TBNA in patients with mediastinal and/or hilar lymphadenopathy and previously conventional TBNA-negative or inadequate results. Methods: Retrospective analysis was performed in 64 patients with previously conventional TBNA- negative or inadequate results and consequently undergoing EBUS-TBNA between July 2007 and August 2011. Results: One hundred and twenty three lymph nodes were sampled by EBUS-TBNA in 64 patients with no complications. In the 63 (98.4%) cases with adequate results, the sensitivity, diagnostic accuracy, and NPV of EBUS-TBNA per patient was 90.5%, 90.6%, and 66.6%, respectively. In a total of 122 (99.1%) adequately sampled lymph nodes, the diagnostic sensitivity, accuracy, and NPV of EBUS-TBNA per nodal station were 87.8%, 90.1%, and 65.7%, respectively. Non-small cell lung cancer (NSCLC) (n = 21, 33.3%) and sarcoidosis (n = 16, 25.3%) were the most common malignant and benign diseases in the patients with adequate samples by EBUS-TBNA. The relationships of diagnostic accuracy with the number of lymph nodes sampled, number of passes per node, or size of lymph nodes were both insignifi cant (p >0.05). Conclusion: EBUS-TBNA is a sensitive and accurate method for the assessment of mediastinal and hilar lymph nodes in patients with conventional TBNA negative results.

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Purpose: Analgesia following thoracotomy is routinely accomplished using epidural blockage performed by anesthesiologists. More effective pain control can be achieved with continuous paravertebral blockage performed by thoracic surgeons. We aimed to retrospectively analyze the efficacy of paravertebral blockage for managing post-thoracotomy pain.Methods: The study included 125 patients who underwent continuous paravertebral blockage for the following types of thoracic surgery: video-assisted thoracoscopic surgery(n = 87), anterior axillary thoracotomy (n = 21), posterolateral thoracotomy (n = 16), and median sternotomy with additional left thoracotomy (n = 1). We retrospectively evaluated the analgesic effects of continuous paravertebral blockage by assessing whether a good cough effort could be performed and whether an additional painkiller was given as a rescue medication.Results: About 115 patients could perform a good cough effort to expectorate sputum immediately after extubation in the operating room. Six patients tolerated postoperative pain well without any oral or rectal non-steroidal anti-inflammatory drugs (NSAIDs). For97 patients postoperative NSAIDs could control thoracotomy pain well. Twenty-two patients were given an additional painkiller stronger than NSAIDs. Three patients complained of nausea postoperatively.Conclusion: Adequate post-thoracotomy pain control was accomplished by continuous paravertebral blockage, with few complications.

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Purpose: Bronchopleural fistula (BPF) is a serious complication following pneumonectomy in lung cancer patients. The aim of this retrospective study is to investigate the efficacy of bronchial stump reinforcement with a collagen fleece coated with fibrin glue(TachoComb^®).Methods: The bronchial stumps of 43 lung cancer patients who underwent pneumonectomy between January 1998 and January 2003 were covered with pericardial fat pad.From February 2003 to the March 2011, we used TachoComb to cover the bronchial stumps of all lung cancer patients undergoing pneumonectomy (20 cases). Several preoperative, intraoperative, and postoperative variables were recorded retrospectively.Results:Univariate analysis of comorbidities and risk factors did not show any significant differences between the two groups except for neoadjuvant chemotherapy. Postpneumonectomy BPF occurred in three of the 43 (7%) patients who had pericardial fat pad coverage and in none of the patients treated by TachoComb.Conclusion:Reinforcement of the bronchial stump with TachoComb is a simple procedure, comparable to coverage with viable tissue, and should be considered in the prevention of postpneumonectomy BPF.

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Purpose: Smoking is a well-known risk factor for postoperative pulmonary complications. As a consequence of pre and postoperative procedures continuing to be developed, postoperative complications continue to decrease. In this study, smoking as a risk factor for postoperative pulmonary complications is studied.
Methods: From January 2005 to June 2009, postoperative pulmonary complications and smoking factors were analyzed from among 232 lung cancer patients with a smoking history. Smoking factors included cessation duration and pack-years. Also, relationships between pulmonary complications and patient factors, including gender, age, histological features, surgery methods, pulmonary function test, and body mass index were analyzed.
Results: Univariate and multivariate analysis revealed that smoking factors were not significant risk factors for the development of postoperative pulmonary complications.
Conclusion: Recently, the effect of smoking on the development of postoperative pulmonary complications has been reduced due to the increase in quality of pre and postoperative management and surgery procedures. Accordingly, there seems to be no need to delay operative procedures to secure a significant duration of smoking cessation duration in lung cancer patients.

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Purpose: Postoperative atrial fibrillation (AF) is a common complication of cardiac surgery that is associated with an increased incidence of other complications. The goal of this prospective randomized study was to evaluate the effect of ultra-low dose landiolol hydrochloride for prevention of AF after off-pump coronary artery bypass grafting (CABG).Methods: The subjects were 47 patients who underwent isolated CABG and were randomly divided into those who received landiolol from ICU admission until the beginning of oral drug intake (Group L) and those administered diltiazem hydrochloride over the same period (Group D). The incidence of AF within one week after surgery was examined as the primary endpoint. Heart rate, blood pressure, cardiac output, and other hemodynamic parameters were used as secondary endpoints. The rates of adverse events were also recorded.Results: The incidences of AF in the first postoperative week were 4.8% and 27% in Groups L and D, respectively (p = 0.046). There were no differences in hemodynamic parameters between the Groups. In multivariate analysis, no factor emerged as a significant risk factor for postoperative AF. Two patients had adverse events of asthma and hypotension, respectively, in Group L.Conclusion: Ultra-low dose landiolol is effective for preventing AF after CABG without worsening hemodynamics.

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Purpose: This study aimed to establish the role of risk factors in the etiology of postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG).Methods: Between September 2001 and March 2008, 1040 patients underwent isolated CABG at our clinic. Nine hundred and eleven of these patients did not have any AF(Non-AF Group) and the other one hundred and twenty-nine had AF (AF Group). A retrospective study was performed for patient, disease and treatment related factors and multivariate analysis was used to identify independent clinical predictors of postoperative AF.Results: Postoperative AF was identified in 129 (12.4%) of the patients, and those were significantly older and had significantly higher additive EuroSCORE score as compared with patients without AF. During the postoperative course, patients with postoperative AF also had significantly higher and prolonged (≥6 hours) mechanical ventilation time, longer and prolonged intensive care unit stay and longer hospital stay. Logistic regression analysis revealed that postoperative AF development ratio was 1.690 times higher when the ventilation time was over 6 hours (OR 1.690, 95% CI 1.092-2.615, p = 0.018); 1.240times higher in the presence of elevated additive EuroSCORE score (OR 1.240, 95% CI1.109-1.385, p = 0.0001); 1.052 times higher in the presence of advanced age (OR 1.052,95% CI 1.031-1.0741, p = 0.0001).Conclusion: Analysis of our data reveals that, patient's age, additive EuroSCORE score, and prolonged ventilation are predictors of postoperative AF. Identification of risk factors might lead to better prevention of this problem and its potential consequences. However, to support our investigation and obtain more reliable evidence, prospective randomized controlled trials are needed.

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Purpose: We assessed the long-term clinical, angiographic, and echocardiographic outcomes of patients with left ventricular dysfunction (ejection fraction ≤40%) who underwent isolated off-pump coronary artery bypass grafting.
Methods: One hundred sixty one patients were included. Mean age was 67.2 ± 11.4 years, and 20 patients (12.4%) were female. Eighty-eight patients (54.7%) were New York Heart Association functional class 3 or 4. Early postoperative and follow-up angiography and echocardiography findings were analyzed, and mid-term survival rates (mean follow-up 40.7 ± 25.6 months) were calculated.
Results: Mean number of distal anastomoses was 4.4 ± 1.3. Bilateral internal thoracic artery grafts were used in 84.5% of patients. Operative mortality was 2.5%. Early patency rate of anastomoses was 98.3%. Early postoperative ejection fraction improved from 33.1 ± 5.6% preoperatively to 36.9 ± 9.5% (p <0.001). Seven-year survival rate was 73.9 ± 5.3%, and freedom from cardiac events rate was 68.5 ± 5.2%. One-year patency rate of anastomoses was 85.8%. Follow-up ejection fraction was 39.1 ± 10.7% (p <0.001).
Conclusions: Early and long-term outcomes of off-pump coronary artery bypass grafting in patients with left ventricular dysfunction were favorable, including early postoperative and follow-up patency rates of anastomoses and echocardiographic recovery of ejection fraction.

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Introduction: Idiopathic mitral valve chordal rupture is rare among infants. Once it has occurred, acute heart failure progresses, and emergency surgical repair is necessary in most cases. Our surgical experience with idiopathic mitral valve chordal rupture is reported.
Patients and Methods: From September 2008 to May 2012, four infants (3 males, 1 female; median age 5.5 months) underwent mitral valve plasty for severe mitral valve regurgitation due to prolapse of posterior mitral valve leaflet. Patient history, surgical procedure, operation time, mortality, postoperative echocardiography data (mitral valve regurgitation grade: 0-trivial, mild, moderate, severe, transmitral flow: TMF) and pathology were examined.
Results: Three cases required emergency surgery; 1 case, elective surgery. Intraoperative findings showed chordal rupture of the P2 segment in 3 cases and P1 + P3 segments in 1 case. Quadrangular resection with annular plication was performed for 1 case. Quadrangular resection with annular plication and the Kay procedure were performed for 3 cases. Mitral valve regurgitation improved from severe to trivial-mild in all cases. Pathological examination showed a myxomatous degenerative change in the mitral valve.
Conclusion: Mitral valve plasty was performed for idiopathic mitral valve chordal rupture in infants. The surgical procedures were the same as for adult cases and achieved satisfactory results.

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Purpose: We examined changes of TR (tricuspid regurgitation) after mitral valve repair for degenerative mitral regurgitation (MR) and investigated their contributing parameters. Methods: We divided 205 patients undergoing mitral valve repair for degenerative MR into 3 groups: up-grade (n = 65), down-grade (n = 29), and no-change (n = 111) of TR during postoperative follow-up. Preoperative, immediate postoperative, and mid-term postoperative parameters included MR grade, right ventricular (RV) pressure, RV Tei index, left ventricular Tei index, and presence of atrial fibrillation.
Results: Preoperative incidence of atrial fibrillation in the down-grade group was lower (7%) than those in the other groups (37% and 34%). In the immediate postoperative stage, the TR grade of the up-grade group was significantly lower (p <0.001) and RV Tei index of the downgrade group was significantly lower (p = 0.049). In mid-term postoperative stage, the TR grade (p <0.001) and RV Tei index (p = 0.034) of the down-grade group were significantly lower, and the MR up-grade in the TR up-grade group was significantly frequent (p = 0.008). Conclusions: TR became deteriorated even after the operation in about 30% and remained unchanged in about 50%. The RV Tei index can be a reliable parameter to predict postoperative improvement of TR. The postoperative MR up-grade was related to the TR up-grade.

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Exostosis occurs in the ribs either sporadically or as a manifestation of a genetic disorder known as hereditary multiple exostoses. Costal exostosis may cause chest pain and, on rare occasions, result in hemothorax, pneumothorax, hemopneumothorax, and diaphragmatic or pericardial laceration. We report a case of pneumothorax in a 16-year-old boy with exostosis in the right seventh and eighth ribs. He previously received a diagnosis of multiple exostoses and underwent costal resection. The lung and pleura were injured because of long-term friction between the exostoses and the visceral pleura.To the best of our knowledge, this is only the fourth report of pneumothorax caused by costal exostosis. Moreover, all previously reported cases of pneumothorax or hemopneumothorax caused by costal exostosis, including the present case, involved lower lobe injury.

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The occurrence of hypoglycemia with an intrathoracic tumor is referred to as Doege- Potter syndrome (DPS). However, the association between hypokalemia and DPS is rare. We report a case of a solitary fibrous tumor of the pleura with refractory hypoglycemia and hypokalemia. A 57-year-old male was admitted to our hospital for unconsciousness. His serum glucose and potassium levels were low. Radiological findings revealed a large tumor occupying the left hemithorax. Despite being treated with glucose and potassium replacement therapy, the patient still suffered from repetitive fasting hypoglycemic and hypokalemia episodes. After the tumor was completely resected, his serum levels of glucose and potassium returned to normal level.

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Introduction: Popliteal artery entrapment syndrome (PAES) is the rare congenital abnormality. It is a threat to the lower extremity due to ischemia in young adults.Case Report: A 32-year-old health worker (medical doctor) applied to our clinic with a complaint of lower extremity pain, paleness, and coldness, post-exercise. He did not have any complaint to make him think as ischemia. Peripheral arterial angiography was applied, but the main diagnosis was given by magnetic resonance imaging angiography. Medical thrombolytic treatment, femoral embolectomy and then tendon resection, approached posteriorly, were applied to the popliteal region.Discussion: Repeated exterior microtraumas cause thickening in the arterial wall, early atherosclerosis, thrombus and ischemia. To diagnose this entity is difficult. Treatment should be surgical, oriented to abolish the compression.Conclusion: In this case, we wanted to emphasize how quiet the progression of the PAES may be, and effacement of the compression is essential in the treatment. Femoral embolectomy does not have any aid to treatment.

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Blunt chest trauma frequently leads to various complications such as pneumothorax, hemothorax, and lung contusion. Since neighboring organ injury caused by a rib fracture with chest trauma could be fatal when a great vessel is involved, immediate diagnosis and treatment including surgery are important. Here, we present a case of chest trauma, in which we performed video-assisted thoracoscopic rib resection to prevent injury to the descending aorta by the fractured rib tip.

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