Purpose: Presence of simultaneous pathological and immunohistochemical nodal metastasis (pNM and iNM, respectively) and/or other clinical factors may be reliable prognostic predictors of survival in esophageal cancer patients who have undergone multidisciplinary treatment.Methods: Univariate and multivariate analysis of the data collected from 77 patients who had undergone R0 esophagectomy was performed to determine the significance of presence of iNM or pNM, presence of simultaneous pNM, and other clinical factors as prognostic indicators in patients who had (n = 40) and had not (n = 37) undergone preoperative treatment.Results: Presence of pNM was found to be a significant prognostic predictor in patients who had undergone preoperative treatment, presence of iNM in patients who had not undergone preoperative treatment, and presence of simultaneous pNM and iNM in both patient groups. Multivariate analysis indicated that the sole prognostic predictor for patients who had undergone preoperative treatment was presence of simultaneous pNM and iNM while that of patients who had not undergone preoperative treatment was clinical T category.Conclusion: Assessment of simultaneous presence of pNM and iNM may facilitate highly accurate prediction of survival in esophageal cancer patients undergoing R0 esophagectomy, regardless of whether they have undergone preoperative treatment.

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Purpose: Recurrence is the most common complication after an initial episode of primary spontaneous pneumothorax (PSP). However, preventive surgery in children remains a controversial issue. The purpose of this study was to determine predictive factors of recurrence to better inform early surgical referrals.Methods: We retrospectively reviewed all consecutive patients under 18 years of age who conservatively treated for an initial episode of PSP between March 2005 and September 2011.Results: One hundred fourteen patients were included in this study. The mean follow-up period was 43.1 months. Ipsilateral and contralateral recurrence developed in 47.3% and 14.0% of patients. The risk of ipsilateral recurrence for patients with or without air-containing lesions according to high-resolution computed tomography (HRCT) was 60.3% and 31.4%. In the multivariate analysis, the presence of air-containing lesions on HRCT scans and bullae on chest X-rays were independent risk factors for ipsilateral recurrence.Conclusion: The presence of bleb or bullae on HRCT scans or chest X-rays after an initial episode of PSP was significantly related to the ipsilateral recurrence in children. If the risk factors are clarified in further studies, hospital stays and the recurrence of PSP after the first episode could be reduced with early video-assisted thoracoscopic surgery.

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Purpose: Recent advances in image diagnostic technology have enhanced the discovery of peripheral small size lung cancers. Here, we examined the utility of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) for the evaluation of grade of tumor malignant potency.Methods: Seventy-nine patients with peripheral small lung cancers (≤2 cm) who underwent surgical resections and preoperative FDG-PET were enrolled. The correlations between the maximum standardized uptake value (SUV_max) and various clinicopathological features related to tumor invasiveness, nodal metastasis, and recurrence were analyzed.Results: The median SUV_max of all tumors was 2.4 (range, 0–16.1). The SUV_max was significantly higher in patients with vascular invasion (5.6 ± 3.5 vs. 2.4 ± 2.4; P <0.0001), lymphatic invasion (4.9 ± 3.7 vs. 2.7 ± 2.6; P = 0.0029), lymph node metastasis (6.1 ± 4.4 vs. 3.0 ± 2.7; P = 0.0022), and recurrences (5.8 ± 3.3 vs. 3.1 ± 3.1; P = 0.0219). Patients with SUV_max ≥2.5 had a significantly higher incidence rate of vascular invasion (56% vs. 7%; P <0.0001), lymphatic invasion (51% vs. 15%; P = 0.0006), lymph node metastasis (26% vs. 3%; P = 0.0033), and recurrence (18% vs. 3%; P = 0.0289). The patients with SUV_max ≥1.5 also had a significantly higher incidence of vascular invasion, lymphatic invasion, lymph node metastasis, and recurrence. It is particularly worth noting that patients with SUV_max <1.5 had no vascular invasion, lymph node metastasis, or recurrence.Conclusion: Preoperative SUV_max of peripheral small lung cancers were significantly associated with tumor malignancy.

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Purpose: The objective of this study was to assess the perioperative results of a single-incision approach using multi-DOF forceps for spontaneous pneumothorax, in comparison with the traditional 3-port approach.Methods: Between May 2012 and June 2013, 44 patients with spontaneous pneumothorax underwent SITS, and their clinical characteristics and perioperative results were evaluated. We then compared those who had undergone SITS (SITS group) with those who had undergone traditional 3-port surgery before the study period (3-port group).Results: The two groups were similar in terms of mean patient age and pneumothorax laterality (p = 0.81, 0.38), but the proportion of male patients was higher in the 3-port group than in the SITS group (p = 0.0026). Operation time in the SITS group (52.4 min) was longer than in the 3-port group (35.9 min, p <0.0001). The duration of postoperative drainage and hospital stay did not differ significantly between the groups (p = 0.19, 0.075). Although 14 of the 56 SITS patients (25%) showed mild adhesion in the pleural cavity, none required conversion to a 3-port approach. The bullous region in two or three lobes was resected in 23 patients (41%).Conclusions: SITS using multi-DOF forceps is a useful approach for treatment of spontaneous pneumothorax in selected patients.

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Purpose: To examine the relationship between the density of tumor-infiltrating T cell subpopulations and the pathological response to induction chemoradiotherapy (CRT) in patients with locally advanced NSCLC, and to assess the impact of T cell density on patient prognosis.Methods: A total of 64 patients with c-stages IIA-IIIB NSCLC who underwent induction CRT followed by R0 surgery were enrolled. Tumor-infiltrating T cells expressing either FOXP3 or CD8 were detected by immunohistochemical staining.Results: Mean numbers of tumor-infiltrating FOXP3+ T cells were 39.9 for patients with minor pathological responses (n = 9), 18.4 for those with major pathological responses (n = 25), and 12.9 for those with complete pathological responses (n = 30; P <0.001). The number of CD8+ T cells was not associated with pathological responses. Patients with lower FOXP3+ T cell densities showed better survival, although the difference was not statistically significant.Conclusion: Our study demonstrated that the density of tumor-infiltrating FOXP3+ T cells indicated the degree of response for induction CRT and prognosis in patients treated with trimodality therapy for locally advanced NSCLC, suggesting that FOXP3+ T cells may be target for adjunct immunotherapy.

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Purpose: Degenerative mitral valve disease is distinguished with billowing mitral leaflet (BML) or fibroelastic deficiency (FED). The purpose of this study is to evaluate the clinical characteristics and the pathohistological differences between BML and FED.Methods: A total of 73 patients who diagnosed as degenerative mitral valve disease pathologically after mitral valve surgery for severe mitral regurgitation were enrolled. On the basis of echocardiographic features and gross appearances, they were classified as BML (9 cases) and FED (64 cases).Results: In the BML group, multiple segments of the leaflet showed billowing with elongated chordae. Therefore excessive valve tissue needed to be removed by multiple resection and suture. The FED patients had focal myxomatous changes with ruptured chordae, a single resection and suture was frequently employed. In pathological examination, the valve thickness of the BML was nearly twice as thick as the FED, and the mucopolysaccharide accumulation of the Spongiosa in the BML was over 50%, while 30% in the FED.Conclusion: BML presents the characteristic valve thickening due to its abnormal production of mucopolysaccharide. Since excessive tissue was voluminous in the BML, high-grade plasty techniques, such as combination of multiple resection and chordal reconstruction were required.

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Purpose: Iliac vein compression syndrome (May-Thurner syndrome) is characterized by left iliac vein obstruction secondary to compression by the right common iliac artery against the fifth-lumbar vertebra, which increases incidence of deep venous thrombosis (DVT). We treated the patients with DVT due to May-Thurner syndrome (MTS) by surgical thrombectomy and simultaneous stenting, and this study is to evaluate the outcomes of this procedure.Methods: From January 2009 to December 2011, a total of 8 patients underwent surgical thrombectomy with stenting. All patients were admitted for acute DVT involving the left iliofemoral segment, and diagnosed MTS. Patients were followed-up, and stent patency was assessed by means of duplex sonography.Results: In all patients, the procedure was successful in achieving re-canalisation of the iliofemoral veins at the end of the operation. Perioperatively, there was no mortality and there was no case of clinically detected pulmonary embolism. Rethrombosis occurred within seven days of operation in 2 patients. During the follow-up period (mean; 16 months), 6 of 8 patients kept patent stents.Conclusion: Venous thrombectomy with simultaneous stenting is a potent technique to treat acute iliofemoral DVT due to MTS. This technique can restore venous patency and provide relief of the acute symptoms.

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Purpose: The number of elderly patients who require surgical treatment for mitral regurgitation (MR) is increasing. However, the feasibility and efficacy of mitral valve repair in elderly patients are unclear.Methods: We retrospectively reviewed 55 patients, aged ≥75 years, who underwent mitral valve repair for degenerative MR between 1991 and 2011. All patients were followed up for 4.7 ± 3.4 years.Results: The patients aged ≥75 years were more symptomatic and had a higher incidence of persistent atrial fibrillation and pulmonary hypertension than those aged <75 years. Thirty-day and in-hospital mortality was 1.8% and 7.3%, respectively, and the 5-year survival rate was 81.6% ± 5.8%. The leading cause of late death was stroke, which primarily occurred in patients with postoperative atrial fibrillation. Except for a single failure of repair due to technical reasons, there was no recurrence of severe MR or reoperation on the mitral valve. In the late follow-up period, the mean left ventricular diastolic diameter significantly decreased and the mean left ventricular ejection fraction was approximately 60%. Most patients had mild symptoms at follow-up.Conclusion: Mitral valve repair can provide satisfactory early as well as long-term outcomes and can preserve left ventricular function even in the elderly.

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Purpose: We describe midterm outcomes after division of secondary chords (chordal cutting) combined with downsized ring annuloplasty for ischemic mitral regurgitation (IMR).Methods: We compared the clinical outcomes in patients who underwent chordal cutting with downsized ring annuloplasty (CC-group, n = 15) and those who underwent conventional ring annuloplasty only (Conventional-group, n = 35) for IMR. Follow-up was complete in all patients. The median follow-up time was 4.1 years.Results: Thirty-day mortality was 0% in CC-group and 20% in Conventional-group. The overall survival rate at 5-year was 80.8% ± 12.6% in CC-group and 61.7% ± 8.4% in Conventional-group (Log-rank, p = 0.145). The freedom rate from valve-related events at 5 year was 84.6% ± 10.0% in CC-group and 65.3% ± 10.1% in Conventional-group (Log-rank, p = 0.213). Recurrence of severe mitral regurgitation was revealed in 3 patients of CC-group. Preoperative tenting height was the significant predictor of mitral regurgitation recurrence. In CC-group, the mean left ventricular ejection fraction was 38.0% ± 14.0%, which was similar to the preoperative value of 40.0% ± 13.2% (p = 0.349).Conclusions: Chordal cutting with downsized ring annuloplasty for IMR is a simple method and provides satisfactory early outcomes. However, it carries with high recurrence of MR especially for patients with high tenting height.

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Objectives: Factor(s) affecting the sac size of an abdominal aortic aneurysm (AAA) after endovascular aneurysm repair (EVAR) remain unclear. We compared the diameter of the aneurysm sac at one year after surgery with the preoperative diameter using CT images.Methods: Patients who underwent EVAR at Juntendo University Hospital were involved. According to the size change in treated lesions of the aorta, patients were categorized into the following 3 groups: shrink (<5 mm of reduction), enlarge (>5 mm of expansion), and no change (size change within 5 mm). The patients’ background, laboratory data, devices used, medications, anatomical characteristics, and presence/absence of postoperative endoleaks were examined.Results: Of the 68 consecutive patients, 23 were excluded. Seventeen patients were classified into the shrink group, 28 patients into the no change group, and no patients into the enlarge group. Patients with higher thrombotic area rate on the preoperative AAA tended to present AAA sac shrinkage (p = 0.05). No other variables affected the size change in this study. In addition, the existence of an endoleak suggested the interference of sac shrinkage.Conclusions: The higher AAA thrombotic area rate tended to associate with AAA sac shrinkage.

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Purpose: With the aging of society in developed countries and advances in surgical technology in recent years, surgery is increasing in elderly patients. When performing surgery in older patients, both surgical outcomes and the maintenance of postoperative quality of life (QOL) are important issues. This study investigated surgical outcomes and postoperative QOL in octogenarians who underwent cardiac valvular surgery.Methods and Results: Fifty-nine (16 males) octogenarians (80–89 years old, mean age, 82.4 ± 2.4 years) underwent cardiac valvular surgery between August 1999 and June 2011. A QOL questionnaire, which included the Barthel Index (BI), Fillenbaum Instrumental Activities of Daily Living (FIADL), and the Vitality Index (VI), was sent to all survivors. Kaplan-Meier analysis was used to assess survival. Hospital mortality was 1.6% (1 patient). The 3-, 5-, and 7-year survival rates were 81.2%, 75.4%, and 67.8%, respectively. The BI showed that 87.5% of patients did not require caregiving, the FIADL showed that 32.5% were highly independent, and the VI showed that 87.5% were motivated to live.Conclusions: Short-term outcomes were satisfactory, with low complication and mortality rates. Mid-term outcomes showed maintenance of the minimal required ADL and good motivation for living. However, independence in social activities was decreased, suggesting the need for comprehensive social support.

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Purpose: We investigated the long-term outcomes of suture/ring tricuspid valve annuloplasty for functional tricuspid regurgitation associated with degenerative mitral regurgitation.Methods: We retrospectively reviewed patients who underwent flexible ring tricuspid valve annuloplasty (n = 120) or suture tricuspid valve annuloplasty (n = 42) for functional tricuspid regurgitation concomitant with surgery for degenerative mitral regurgitation (mean follow-up duration, 5.3 ± 5.1 years).Results: The mean age of patients was 62.5 ± 13.1 years. Thirty-day mortality was zero in the suture group, and 0.8% in the ring group. Tricuspid regurgitation grade at discharge was lower in the ring group ( p = 0.002). No difference was observed between survival and freedom from major cardiac/cerebrovascular adverse events between the groups. However, freedom from ≥moderate tricuspid regurgitation was higher in the ring group (Log-rank p = 0.003). From univariate analysis, the risk factors for ≥moderate TR were suture annuloplasty and preoperative tricuspid regurgitation grade. No reoperation for recurrent tricuspid regurgitation occurred in either group because symptoms experienced by patients with recurrent tricuspid regurgitation were relatively insignificant.Conclusion: Concomitant tricuspid annuloplasty using flexible bands offered improved durability than suture annuloplasty for preventing postoperative tricuspid regurgitation progression.

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A variety of disease in the chest can be treated with thoracoscopic surgery. Although with limited experience, thoracoscopic surgery can be performed with single-port approach. Theoretically, single-port approach can be applied in treating bilateral pleural effusions. Here we reported a case of 28-year-old man with the diagnosis of septic embolization of the lung with complications of bilateral empyema. He was treated with single-port thoracoscopic surgery for decortication of right pleural space and deloculation of left pleural space. After prolonged course of antibiotics for 21 days, the patient was discharged. After follow-up for 3 months, the patient recovered well and had no evidence of recurrence.

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Introduction: Patients with acute aortic dissection type A (AADA) with aortic arch and supra-aortic vessel involvement have a higher postoperative stroke prevalence and risk of later aortic arch aneurysm development.Case Report: We report a case of AADA with involvement of supraaortic arteries, complicated by cerebral malperfusion. The ascending aorta was replaced using bilateral antegrade cerebral perfusion through side-grafts attached to both carotid arteries, which were subsequently used as aorto-bi-carotid bypass. One year later, the diameter of aortic arch increased to 5 cm. The endovascular treatment of aortic arch was easily performed since debranching was already almost complete.Conclusions: Immediate bilateral carotid artery inflow and subsequent aorto-bi-carotid bypass is a safe way to prevent cerebral malperfusion in the setting of complicated AADA.A potential benefit of this technique is almost complete debranching that facilitates an endovascular arch replacement.

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