Background: In the elderly patients, optimal surgical treatment can be difficult to achieve, because of comorbidity. Therefore, we aimed to clarify the preferred surgical management in this patient group.Methods: A retrospective study was conducted between April 2008 and March 2015 that included patients with non-small cell lung cancer (NSCLC) aged ≥ 75 years.Results: We included 44 patients who underwent partial resection (n = 20) or lobectomy (n = 24). There were no significant differences between the two groups on most variables, except for some character. Survival analysis revealed a significant difference in overall survival (OS) between the two groups; however, no significant differences existed in the disease-free survival or in the OS for stage I disease. Postoperative complications led to poor prognoses. Cox regression analysis revealed statistical significance for the Brinkman Index, the ratio of the pulmonary artery diameter to the ascending aorta diameter (PA:A), and the alveolar–arterial oxygen gradient. Only the PA:A ratio remained significant after multivariate analysis, with a higher ratio associated with better survival.Conclusion: In elderly patients with NSCLC, surgical resection should not be denied because of age alone. However, partial resection should be favored to lobectomy when possible.

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Introduction: Deteriorated alveolar structure at the base of blebs and bullae is known as the reticulated trabecula-like structure. Its clinical significance in primary spontaneous pneumothorax (PSP) remains unclear. This study aimed to investigate the impact of the structure on recurrence of PSP after video-assisted thoracoscopic surgery (VATS) bullectomy.Methods: Between April 2010 and March 2014, 80 cases of PSP in 76 patients who underwent VATS bullectomy using endoscopic staplers were included. The staple line was covered with polyglycolic acid sheets and fibrin glue. Cases were assigned to a normal alveolar structure (NAS) group (n = 54) and a reticulated trabecula-like structure (RT) group (n = 26) based on the histological analysis. Factors associated with recurrence were analysed using logistic regression.Results: The reticulated trabecula-like structure was significantly related to apical lung blebs. The recurrence rate of PSP was significantly higher in the RT group than in the NAS group (38.5% vs. 3.7%; P <0.001). On multivariate analysis, the reticulated trabecula-like structure was an independent factor for recurrence of PSP after VATS bullectomy.Conclusion: The change of alveolar structure at the base of apical lung blebs would increase the risk for recurrence of PSP after VATS bullectomy.

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Purpose: To assess the frequency of airflow limitation (AFL), and the relationship between AFL and preoperative comorbidities or postoperative complications in patients who had undergone thoracic surgery.Methods: The medical records of patients who underwent non-cardiac thoracic surgery at our institution between August 1996 and January 2013 were retrospectively reviewed. On the basis of preoperative pulmonary function tests, patients were classified with those with FEV₁/FVC <70% [AFL(+) group] or with FEV₁/FVC ≥70% [AFL(−) group]. Patient characteristics, preoperative comorbidities and postoperative complications were compared between the groups.Results: Of the 3667 patients assessed, 738 (20.1%) were allocated to the AFL(+) group. AFL was an independent risk factor for three preoperative comorbidities: chronic obstructive pulmonary disease (odds ratio [OR]: 4.65), bronchial asthma (OR 4.30) and cardiac diseases (OR 1.41). Airflow limitation was also an independent risk factor for postoperative respiratory failure including long-term oxygen therapy (OR 2.14) and atelectasis (OR 1.90) in the patients who underwent lobectomy or partial resection of the lung.Conclusions: Our retrospective study revealed that careful attention needs to be paid to airflow limitation in patients who undergo non-cardiac thoracic surgery since it appears to be an important feature of preoperative comorbidities and to increase postoperative complications.

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Purpose: To investigate tracheal reconstruction with autologous bladder wall using modern refined surgical procedures.Methods: Experiments were performed on 16 female beagle dogs. Six tracheal cartilages were resected to create a tracheal deficit, then tracheal replacement with autologous bladder wall was performed. In the first 10 dogs (first series), the transplant site was covered with pedicled omental flap. In the next six dogs (second series), we performed tracheal reconstruction without omental covering, and secured tracheal cartilages above and below the graft with sutures to prevent excessive graft stretching. Results: No surgical mortality or lethal infection of the transplant site was encountered in either series. Complications in the first series comprised tracheal stenosis in four dogs. One dog died suddenly at 4 months postoperatively due to stent migration, so cartilage sutures were adopted in the second series. The lumen surface of the grafts was covered with squamous metaplastic epithelium. Osseous tissue was present in the submucosa of grafts, particularly prominently in areas lacking omental covering.Conclusions: Tracheal reconstruction using bladder wall may become clinically useful. A pedicled omental covering does not appear always necessary to prevent graft necrosis and infection. Ischemic stimulation may be involved with bone formation in grafts.

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Background: Angiotensin II receptor blockers (ARBs) have been widely used to treat hypertension and large-scale clinical studies have shown various benefits. In this study, we compared olmesartan with azilsartan, the newest ARB.Methods: The subjects were outpatients who were clinically stable after cardiac surgery. Sixty patients were randomized to receive either azilsartan or olmesartan for 1 year and were switched to the other drug for the following 1 year. The primary endpoints were the levels of plasma renin activity, angiotensin II, and aldosterone. Results: Home blood pressure exceeded 140/90 mmHg and additional antihypertensive medication was administered to 12 patients (20 episodes) in the azilsartan group versus 4 patients (4 episodes) in the olmesartan group, with the number being significantly higher in the azilsartan group. After 1 year of treatment, both angiotensin II and aldosterone levels were significantly lower in the olmesartan group than the azilsartan group. Left ventricular mass index was also significantly lower in the olmesartan group than the azilsartan group.Conclusion: This study showed that olmesartan reduces angiotensin II and aldosterone levels more effectively than azilsartan. Accordingly, it may be effective in patients with increased renin-angiotensin-aldosterone system activity after cardiac surgery or patients with severe cardiac hypertrophy.

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Purpose: In cardiac surgery candidates, a concomitant history of breast cancer suggests adverse outcomes. The possibility of internal mammary artery (IMA) utilization and its patency rate is frequently discussed. Secondary, blood loss and wound related infections might be important issues. However, publications focusing on these issues are limited.Methods: We analyzed 32 patients with previously treated breast cancer undergoing cardiac bypass (CABG) and combined CABG surgery matched to 99 control subjects in a retrospective cohort study. Patients were analyzed regarding IMA utilization, blood loss and substitution and frequent perioperative complications as well as long-term mortality.Results: No significant differences between groups were observed regarding duration of surgery, IMA-utilization, incidence of infections and postoperative complications or mortality. A pronounced decline of hemoglobin/hematocrit was evident within the first 6 postoperative hours (3.3 ± 1.8 vs. 2.5 ± 1.8 mg/dl; p = 0.03) in breast cancer patients not related to an increased drainage loss but associated with an increase of international normalized ratio (INR) (0.39 ± 0.16 vs. 0.29 ± 0.24; p <0.01).Conclusion: In breast cancer patients, CABG and combined CABG procedures can safely be performed with comparable short- and long-term results.

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Purpose: We collected our experience in the use of chimney technique with endovascular aneurysm repair (Ch-EVAR) for juxtarenal aortic aneurysms (JAAs), and reviewed the outcomes.Methods: The patients who were treated with Ch-EVAR between January 2012 and December 2015 were retrospectively reviewed. All of the patients underwent endovascular aneurysm repair (EVAR) under general anesthesia. Femoral arterial access was obtained to place the main body of the endograft; brachial or axillary access was obtained to perform the placement of the chimney stent.Results: We treated 12 patients with 15 renal arteries using the Ch-EVAR procedure. Technical success was achieved in 11 of the 12 (91.6%) cases. Within the first 30 days of postoperative period, the target vessel patency rate was 93.3% (14 of 15 renal arteries). After a median follow-up period of 28 months, one patient required Ch-EVAR-related re-intervention due to a type Ia endoleak, and 13 of the 15 renal arteries were patent at the end of the follow-up period.Conclusion: Our findings demonstrate that Ch-EVAR can be completed with a high rate of success. Although early target vessel occlusion or early postoperative mortality might occur, Ch-EVAR could be an alternative treatment for JAA, especially in high risk patients.

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Purpose: The aim of this study was to elucidate the characteristics of chronic hemodialysis (HD) patients requiring surgery during the active phase of infective endocarditis (IE).Methods: From December 2004 to July 2015, 58 patients underwent surgery in our institute for active IE. Seven patients had been on HD for 1–15 years. Their preoperative profiles and surgical outcomes were compared to those of the other 51 patients (non-HD group).Results: The predominant causative microorganisms in the HD group were Staphylococcus spp, particularly methicillin-resistant Staphylococcus aureus (MRSA), whereas Streptococcus spp were predominant in the non-HD group. Prosthetic dysfunction (stuck valve after mechanical and structural valve dysfunction following bioprosthetic valve replacement), complete atrioventricular (AV) block, and annular abscess formation were more frequent in the HD group. In-hospital mortality was higher in the HD group (29% vs. 6%, p = 0.044). Actuarial survival in the HD and non-HD groups was 43% vs. 87% at 5 years and 43% vs. 76% at 10 years (p = 0.007).Conclusions: Early and long term outcomes in patients with chronic HD were poor. Compared to other patients, chronic HD patients undergoing valve surgery during active IE had higher incidences of MRSA infection, annular abscess formation, postoperative valve dysfunction, and postoperative complete AV block.

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We performed preoperative proton beam therapy for locally advanced thymoma and subsequently achieved complete resection. The patient was 31-year old woman, in whom chest computed tomography revealed a huge mass at the left anterior mediastinum. We diagnosed locally advanced type B3 thymoma. Because of the potential for complications to the lung and heart, definitive photon radiation therapy would have been difficult to administer. Therefore, we performed proton beam therapy, which could be administered within dose limitations. After proton beam therapy, the huge tumor had remarkably decreased in size. We were thereby able to achieve complete resection. As of 24 months after surgery, the patient has not developed any severe adverse events associated with proton beam therapy. Our experience suggests that preoperative proton beam therapy may be an effective modality for reducing tumor size, facilitating complete resection, and preventing toxicity of radiation therapy.

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Birt-Hogg-Dubé syndrome (BHDS) is a rare hereditary disease that presents with multiple lung cysts and recurrent pneumothorax. These cysts occupy predominantly the lower-medial zone of the lung field adjacent to the interlobar fissure, and some of them abut peripheral pulmonary vessels. For the surgical management of pneumothorax with BHDS, the conventional approach of resecting all subpleural cysts and bullae is not feasible. Thus, after handling several bullae by using a stapler or performing ligation as a standardized treatment, we applied to a pleural covering technique to thicken the affected visceral pleura and then to prevent recurrence of pneumothorax. We herein report the successful application of a pleural covering technique via thoracoscopic surgery to treat the recurrent pneumothorax of a 30-year-old man with BHDS. This technique is promising for the management of intractable pneumothorax secondary to BHDS.

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Closure of a patent ductus arteriosus (PDA) in the elderly is a high-risk procedure because of tissue fragility and many possible complications. The patient in our case was an 81-year-old woman with a window-type PDA caused by cardiac failure. Based on the anatomy of the PDA and aorta and to minimize invasion, we used a stent graft to close the PDA. This approach was successful; hemodynamics improved and ductus flow was eliminated during the follow-up period without intervention from the pulmonary artery side.

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