Purpose: Video-assisted thoracic surgery (VATS) techniques have been widely used for resection of mediastinal tumors. This study investigated the usefulness of the subxiphoid approach in thoracoscopic thymectomy.

Methods: In all, 36 patients with anterior mediastinal tumor underwent thymectomy using the subxiphoid approach in two Japanese institutions. These patients were retrospectively reviewed and analyzed.

Results: There were 16 females and 20 males with a mean age of 57 years. Five patients underwent partial thymectomy (PT), 27 underwent total or subtotal thymectomy, and 4 underwent thymectomy with combined resection (CR) of the surrounding organs or tissues. The mean maximum tumor diameter, amount of resected tissue, and blood loss were 4.1 cm, 72.5 g, and 20.6 g, respectively. More than half of tumors were diagnosed as thymoma (n = 19). The operation time was prolonged with a greater volume of thymectomy. The duration of chest tube drainage and postoperative stay were 1.7 ± 1.0 days and 5.9 ± 7.6 days, respectively. Four patients suffered intraoperative and postoperative complications, as follows: bleeding of the innominate vein, bleeding of the internal thoracic vein, crisis of myasthenia gravis (MG), pericarditis, and phrenic nerve paralysis. There were no mortalities after surgery.

Conclusion: Subxiphoid thoracoscopic thymectomy might be a safe and useful approach for mediastinal tumors.

Purpose: To discuss the cost–benefit performance (CBP) and establish a medical fee system for robotic-assisted thoracic surgery (RATS) under the Japanese National Health Insurance System (JNHIS), which is a system not yet firmly established.

Methods: All management steps for RATS are identical, such as preoperative and postoperative management. This study examines the CBP based on medical fees of RATS under the JNHIS introduced in 2016.

Results: Robotic-assisted laparoscopic prostatectomy (RALP) and robotic-assisted partial nephrectomy (RAPN) now receive insurance reimbursement under the category of use of support devices for endoscopic surgery ($5420 and $3485, respectively). If the same standard amount were to be applied to RATS, institutions would need to perform at least 150 or 300 procedures thoracic operation per year to show a positive CBP ($317 per procedure as same of RALP and $130 per procedure as same of RAPN, respectively).

Conclusion: Robotic surgery in some areas receives insurance reimbursement for its “supportive” use for endoscopic surgery as for RALP and RAPN. However, at present, it is necessary to perform da Vinci Surgical System Si (dVSi) surgery at least 150–300 times in a year in a given institution to prevent a deficit in income.

Purpose: This study was performed to compare the outcome of pleurectomy/decortication (P/D) with that of extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM).

Methods: Patients with MPM underwent either P/D or EPP from August 2008 to December 2014. Various clinicopathological factors were analyzed to identify differences between the two procedures.

Results: P/D was performed in nine patients and EPP in 30 patients. Most of the patients’ background characteristics were not significantly different between the groups. The surgery time (680 vs. 586 min, p = 0.0034) and bleeding volume (4050 vs. 2110 mL, p = 0.002) were significantly greater in P/D than in EPP; however, grade ≥3 complications (44% vs. 33%, p = 0.54) and length of postoperative hospital stay (29 vs. 37 days, p = 0.26) were not significantly different. The median survival time and 2- and 3-year survival rates in all patients were 16.7 months, 28.5%, and 15.3%, respectively. The median survival time and 2- and 3-year survival in the P/D and EPP groups were 22.5 months, 43.8%, and 43.8% and 16.5 months, 24.0%, and 14.4%, respectively (p = 0.13).

Conclusion: Survival of patients with MPM remains poor despite multidisciplinary treatment. P/D is comparable with EPP and could be a safe and another surgical treatment for patients with MPM.

Purpose: Selective cerebral perfusion with the open proximal technique for thoracoabdominal aortic repair has not been conclusively validated because of its procedural complexity and unreliability. We report the clinical outcomes, particularly the cerebroneurological complications, of an open proximal procedure using selective cerebral perfusion.

Methods: A retrospective chart review identified 30 patients between 2007 and 2015 who underwent aortic repair through left lateral thoracotomy with selective cerebral perfusion, established through endoluminal brachiocephalic and left carotid artery and retrograde left axillary artery.

Results: The mean durations of the open proximal procedure and cerebral ischemia (the duration of the open proximal procedure minus the duration of selective cerebral perfusion) were 110.3 ± 40.1 min and 24.8 ± 13.0 min, respectively. There were two cases (7%) of permanent neurologic dysfunction (PND) but no in-hospital deaths. Multivariate analysis identified the duration of cerebral ischemia as an independent risk factor for neurologic complications including temporary neurologic dysfunction (TND; odds ratio (OR): 1.13; p = 0.007), but no correlation was found between selective cerebral perfusion duration and neurologic complications.

Conclusion: Despite the relatively long duration of the open proximal procedure, selective cerebral perfusion has a potential to protect against cerebral complications during thoracic aortic repair through a left lateral thoracotomy.

Purpose: Coarctation of the aorta (CoA) in adolescents and adults is relatively rare. Several operative techniques for CoA in adolescents and adults have been reported, but there is still no consensus. This study aims to highlight the use of individual patient characteristics to select optimal treatment strategies for CoA in adolescents and adults.

Methods: Surgical repair of CoA was performed in five patients (mean age: 34 ± 14 years, range: 13–58 years). All patients had primary CoA, and one had aneurysm above the CoA. One patient had undergone previous aortic valve replacement (AVR) and graft replacement of the ascending aorta. One patient underwent resection of the coarctation without cardiopulmonary bypass (CPB) followed by direct end-to-end anastomosis. Three patients underwent CoA resection with an interposition graft through a lateral thoracotomy with partial CPB. One patient underwent AVR with extra-anatomical bypass (ascending–descending aorta).

Results: No in-hospital deaths occurred, and there were no complications. During the follow-up period, there has been no recurrence of CoA.

Conclusion: CoA in adolescents and adults is associated with different issues from those encountered in infant patients, and comprehensive surgery should be performed in all cases.

Aortic valve replacement (AVR) for patients with functioning internal mammalian artery (ITA) grafts is technically challenging, and the optimal treatment strategy for these situations remains controversial. Here, we report five cases of AVR with ITA graft using continuous retrograde cardioplegia in addition to moderate hypothermia without the clamping of ITA and discuss the management of these cases.

Although the technology of endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA) is evolving that make it appealing for challenging anatomy, proximal aortic neck morphology, especially severe angulation, is still one of the most determinants for a successful procedure. We describe a patient of AAA with severely angulated proximal neck, in whom kinked stent graft limb occurred against severe angulation of proximal neck. Then, we suggested how to prevent this complication in the second patient. Our case demonstrated the stent graft limb could be kinked by severe aortic neck angulation, making it challenging. However, the kinked stent graft limb could be prevented by deploying stent graft limbs below the most severely angulated aortic neck intentionally.

A 64-year-old man was admitted for evaluation of back pain. He did not have a Marfan syndrome (MFS)-like appearance, and had a history of a type B aortic dissection and total arch replacement. A connective tissue disorder had been suspected because of the histologic findings of the resected aortic wall. On admission, a computed tomography (CT) scan demonstrated a three-channeled aortic dissection (3ch-AD) measuring 63 mm in diameter. We planned to perform elective surgery during his hospitalization. On the fourth hospital day, he complained of severe back pain, and enhanced CT scan revealed an aortic rupture. The patients with 3ch-AD often have MFS. However, even if they do not have an MFS-like appearance, clinicians should consider fragility of the aortic wall in patients with 3ch-AD. If the aortic diameter is enlarged, early surgery is recommended. In particular, if a connective tissue disorder is obvious or suspected, emergent surgery is warranted.