Purpose: Thoracic surgery is commonly performed for the management of conditions involving the lungs, mediastinum, pleura, and chest wall. Despite advances in surgical techniques and perioperative care, postoperative pain remains a frequent complication. In some patients, pain may persist and progress into chronic post-thoracotomy pain syndrome (CPTPS), defined as pain lasting more than 2 months after surgery. The prevalence of chronic pain ranges from 21% to 91%, with lower rates observed in minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) (~35.5%) and robotic-assisted thoracic surgery (RATS) (11.2%–34.6%).

Methods: This study presents a literature review evaluating the epidemiology, pathophysiology, and management of CPTPS, including pharmacological, interventional, and rehabilitation-based approaches, as well as emerging biological therapies.

Results: Chronic pain is multifactorial, involving tissue injury, inflammation, intercostal nerve damage, and central sensitization. It is associated with impaired respiratory function, reduced mobility, sleep disturbances, and decreased quality of life. Multimodal analgesia and regional anesthesia are key strategies, while rehabilitation supports functional recovery. Emerging biological therapies show promise but remain limited in evidence.

Conclusion: A multidisciplinary approach is essential to reduce CPTPS and improve long-term outcomes and quality of life.

Purpose: Posterior rib fractures represent severe thoracic trauma and are associated with a higher risk of complications due to their proximity to vital intrathoracic structures, including the intercostal vessels and lungs. Surgical stabilization of rib fractures (SSRF) has emerged as an operative strategy to restore chest wall stability, improve respiratory mechanics, and reduce pain. However, evidence specifically addressing posterior rib fractures remains limited, and current understanding is largely extrapolated from studies involving general rib fracture populations.

Methods: This literature review evaluates the principles, operative techniques, effectiveness, and limitations of SSRF in posterior rib fractures, with an emphasis on surgical timing, technical challenges, and postoperative rehabilitation.

Results: Current evidence suggests that SSRF may reduce respiratory complications and improve outcomes in selected patients. Studies report reductions in pneumonia incidence and up to a 95% decrease in tracheostomy requirements in patients with flail chest. Surgical timing also influences outcomes, with pneumonia reported in 18% of patients undergoing SSRF within 72 h compared with 58% in those receiving delayed stabilization.

Conclusions: SSRF may provide clinical benefits in appropriately selected patients with rib fractures. However, evidence specifically addressing posterior rib fractures remains limited, and further high-quality studies are required to clarify optimal indications and surgical strategies.

Endovascular aneurysm repair (EVAR) has markedly reduced perioperative morbidity and mortality in the management of abdominal aortic aneurysms. However, its long-term durability remains a concern because of sac expansion, endoleaks, and late rupture. Sac shrinkage serves as a key surrogate marker of procedural success, reflecting favorable remodeling and a lower risk of complications. Sac behavior after EVAR is determined by the interplay between intrasac pressure and aneurysm wall integrity. Although pressure reduction is essential, wall degeneration and stiffness critically influence remodeling outcomes. The presence of simple renal cysts, a localized manifestation of systemic connective tissue degeneration, has been associated with impaired sac shrinkage and may indicate unfavorable remodeling. Arterial stiffness, assessed by pulse wave velocity, also correlates with sac behavior: lower stiffness favors shrinkage, whereas higher stiffness is linked to expansion or lack of shrinkage. These findings suggest that sac remodeling is a multifactorial process not solely dependent on flow exclusion. Future prospective studies integrating artificial intelligence, vascular remodeling inhibition, and stent graft innovation are warranted to refine patient-specific risk stratification, guide individualized surveillance, and promote sac shrinkage, thereby improving outcomes after EVAR.

Prone minimally invasive esophagectomy offers several technical advantages; however, in obese patients, increased abdominal pressure may contribute to diaphragmatic elevation, leading to difficulty in first-port placement and compromised operability in the lower mediastinum. These technical challenges can be particularly relevant in robot-assisted procedures, where adequate working space and sufficient inter-arm distance are required. We describe a positioning modification using a 4-point support frame in obese patients undergoing prone minimally invasive esophagectomy. By supporting the thorax and pelvis while allowing the abdomen to hang freely, this strategy is intended to reduce abdominal compression and prevent diaphragmatic elevation. In our preliminary institutional experience, this approach facilitated port placement in the standard configuration and provided stable lower mediastinal exposure. Although based on a limited series, this positioning technique may represent a practical and reproducible option for selected obese patients undergoing prone minimally invasive esophagectomy.

We describe a surgical strategy combining on-pump beating-heart coronary artery bypass grafting (OPBH CABG) with left ventricular (LV) venting for patients with advanced ischemic cardiomyopathy (ICM) with severe LV dysfunction and marked LV dilation. This strategy provides LV decompression, reduces myocardial workload, and improves surgical exposure during coronary anastomosis, facilitating complete revascularization. Between January 2013 and September 2024, 7 patients underwent OPBH CABG with LV venting. Six patients had chronic ICM with dilated ventricles and severe systolic dysfunction, and 1 presented with acute coronary syndrome and impaired LV function. The median age was 65 years (interquartile range [IQR], 61–80). The median left ventricular ejection fraction was 21.7% (IQR, 19.2–27.9), and the median left ventricular end-diastolic diameter was 61.6 mm (IQR, 58.7–69.3). Complete revascularization was achieved in all patients without additional mechanical circulatory support. There were no in-hospital deaths or postoperative complications. This strategy may enable complete revascularization in selected high-risk patients while contributing to myocardial unloading.

Purpose: Surgical treatment for pulmonary aspergillosis remains technically demanding because of dense pleural adhesions, chronic inflammation, and the risk of major bleeding. We evaluated temporal changes in patient characteristics, perioperative management, and surgical outcomes over a 30-year period at a single institution.

Methods: We retrospectively reviewed 57 consecutive patients who underwent surgery for pulmonary aspergillosis between 1992 and 2023. Patients were divided into an early era (1992–2007, n = 23) and a late era (2008–2023, n = 34). Clinicopathological characteristics, operative variables, perioperative management, and postoperative outcomes were compared.

Results: Hemoptysis or bloody sputum and previous pulmonary tuberculosis were significantly less frequent in the late era. Lobectomy was the most common procedure, while video-assisted thoracoscopic surgery was introduced during the later period. Operative time (350 vs. 250 min, p = 0.016) and median blood loss (750 vs. 178 mL, p = 0.003) were significantly reduced in the late era. However, the incidence of major postoperative complications and overall survival did not differ significantly between the 2 eras.

Conclusion: Surgical management of pulmonary aspergillosis has evolved with improvements in operative efficiency and blood loss while maintaining acceptable perioperative and long-term outcomes. Careful patient selection and multidisciplinary perioperative management remain essential, particularly for patients with chronic pulmonary aspergillosis.

Purpose: This multi-institutional study investigated the clinical and prognostic significance of serum p53 antibody (s-p53-Ab) titers in patients with s-p53-Ab-positive esophageal squamous cell carcinoma (ESCC) treated with neoadjuvant chemotherapy (NAC).

Methods: We analyzed 637 patients who underwent surgery at 15 institutions. Patients were divided into upfront surgery (n = 375) and NAC (n = 262) groups and stratified into high-titer (≥9.82 ng/mL) and low-titer (>1.30 to <9.82 ng/mL) groups.

Results: In the upfront surgery group, high-titer patients had significantly worse relapse-free survival (P = 0.046) and overall survival (P = 0.024) than low-titer patients. In contrast, no significant survival differences were observed by titer after NAC, and the poorer prognosis associated with high s-p53-Ab titers in the upfront surgery cohort was not seen after NAC. Subgroup analyses of stage II and III disease showed similar, nonsignificant trends toward improved outcomes in high-titer patients after NAC.

Conclusions: These findings suggest that high s-p53-Ab titers are associated with a poor prognosis in patients undergoing upfront surgery. Although these observations did not reach statistical significance, patients with high titers may potentially benefit from NAC, indicating its potential therapeutic value in those with a strong p53 antibody response.

Purpose: We examined whether false lumen-origin segmental arteries (SAs) were associated with postoperative spinal cord injury (SCI) after surgery for acute Stanford type A aortic dissection (ATAAD).

Methods: We reviewed 201 consecutive patients who underwent open repair for ATAAD between January 2008 and February 2026. After prespecified exclusions, 124 patients were analyzed, including 83 with evaluable contrast-enhanced computed tomography for detailed SA assessment.

Results: Postoperative SCI occurred in 9 patients (7.3%), who comprised the SCI group; the remaining 115 comprised the non-SCI group. Total arch replacement and frozen elephant trunk use were numerically more frequent in the SCI group. In the detailed cohort, the number of false lumen-origin SAs was higher in the SCI group at T3–T7 (7.2 ± 3.0 vs. 3.9 ± 3.1, P = 0.042) and T8–L2 (10.3 ± 2.7 vs. 5.5 ± 4.2, P = 0.005). The corresponding proportions were also higher at T3–T7 (77.5% vs. 45.2%, P = 0.047) and T8–L2 (75.0% vs. 41.9%, P = 0.010).

Conclusion: In this exploratory single-center cohort, false lumen-origin SAs were associated with postoperative SCI in unadjusted analyses. Further studies are needed to determine their value for preoperative risk stratification.

Purpose: This study aimed to identify the preoperative and intraoperative predictors of direct home discharge in patients following surgical repair for acute type A aortic dissection (ATAAD).

Methods: We included patients with ATAAD who underwent surgical repair between 2012 and 2025. Patients were categorized into 2 groups based on their discharge destination. Multivariable logistic regression analysis was performed to identify independent predictors of direct home discharge.

Results: Among 277 patients, 133 (48.01%) were discharged directly home. Multivariable logistic regression analysis revealed that age (per year, odds ratio [OR], 0.961; 95% confidence interval [CI], 0.936–0.986; P = 0.003), living alone (OR, 0.523; 95% CI, 0.277–0.985; P = 0.045), cardiac tamponade (OR, 0.434; 95% CI, 0.203–0.927; P = 0.031), and neurological deficits of the extremities (OR, 0.369; 95% CI, 0.161–0.845; P = 0.018) were significant independent predictors of direct home discharge. The area under the receiver operating characteristic curve was 0.731.

Conclusion: Advanced age, living alone, preoperative cardiac tamponade, and neurological deficits of the extremities are significant predictors of a reduced likelihood of direct home discharge following surgical repair for ATAAD.

Purpose: Skip N2 metastasis in non-small-cell lung cancer (NSCLC) confers a favorable prognosis, yet the biological determinants remain poorly defined. We investigated lymphatic drainage patterns and histological characteristics to develop a novel pN2 subclassification.

Methods: We retrospectively analyzed 180 consecutive pN2 patients (2015–2022); 50 exhibited skip metastasis. Lymphatic drainage was classified as direct, indirect, or mixed, and a composite score incorporating drainage, histology, grade, and lymphovascular invasion stratified patients into 3 risk groups. Survival was assessed with Kaplan–Meier and Cox models.

Results: Skip metastasis was associated with superior KM-estimated 5-year overall survival compared to non-skip disease (56% vs 41%; median follow-up 43 months, with 34% of patients reaching the 5-year assessment). Direct drainage predominated in peripheral upper-lobe tumors and correlated with lower lymphovascular invasion. The model distinguished 3 prognostic groups: low-risk (5-year survival 71%), intermediate-risk (55%), and high-risk (27%). The subclassification was an independent prognostic factor, with high-risk patients showing an adjusted hazard ratio of 2.45 (95% CI 1.42–4.23).

Conclusion: Integrating lymphatic drainage and histology refines prognosis in pN2 lung cancer and provides a hypothesis-generating framework for prognostic stratification of skip N2 disease, with potential to inform future clinical trial design pending validation.

Purpose: We developed a quantitative method to evaluate aortic atheroma and investigated its association with postoperative cerebral infarction (CI) after aortic arch surgery. In addition, computational fluid dynamics (CFD) analysis was performed to explore the underlying hemodynamic mechanisms.

Methods: We retrospectively analyzed 72 patients who underwent aortic arch surgery. Atheroma scores were calculated from preoperative computed tomography, and a qualitative assessment was also performed. Multivariate logistic regression identified risk factors for CI. CFD analysis was conducted in selected patients to provide mechanistic insights.

Results: CI occurred in 8 patients (11.1%). Atheroma scores were significantly higher in patients with CI (P = .02), whereas qualitative assessment did not predict CI. Receiver operating characteristic analysis showed an area under the curve of 0.79 for the ascending aorta, with a cutoff of 352.3. Multivariate analysis including age demonstrated that hemoglobin A1c and an ascending atheroma score ≥352.3 were independent predictors of CI. CFD demonstrated high wall shear stress in the ascending aorta, providing mechanistic insight into embolic events.

Conclusions: Quantitative assessment of ascending aortic atheroma provides superior risk stratification compared with qualitative evaluation. CFD findings offer mechanistic insight into embolic risk, supporting the clinical relevance of atheroma burden in aortic arch surgery.

Purpose: Given the limited Japanese real-world evidence, this study aimed to evaluate the survival and safety of adjuvant nivolumab after neoadjuvant chemotherapy in patients with an incomplete pathological response to esophageal squamous cell carcinoma (ESCC).

Method: This single-center retrospective study included 105 of 259 patients with ESCC who had an incomplete pathological response after neoadjuvant chemotherapy and esophagectomy. Recurrence patterns and immune-related adverse events (irAEs) were analyzed, and disease-free survival (DFS) and overall survival (OS) were compared between the nivolumab and non-nivolumab groups before and after propensity score matching (PSM).

Result: Among 105 patients, 17 received adjuvant nivolumab. Median follow-up was 26.8 months; recurrence occurred in 33 patients (31.4%), and irAEs occurred in 2 nivolumab-treated patients (11.8%). Before PSM, OS and DFS were not significantly different between 2 groups. After PSM, OS remained nonsignificant (P = 0.202), whereas DFS showed a favorable trend toward improvement in the nivolumab group, with 1-year DFS rates of 75.0% versus 68.8% and 3-year DFS rates of 68.2% versus 19.3%, respectively (P = 0.067). Nivolumab was not an independent prognostic factor, although exploratory high-risk subgroups showed favorable DFS trends.

Conclusion: Adjuvant nivolumab showed a nonsignificant favorable trend in DFS after PSM, with late curve separation favoring the nivolumab group and manageable irAEs.

Purpose: Patients on hemodialysis (HD) undergoing coronary artery bypass grafting (CABG) face a high risk of perioperative complications, and the optimal timing of perioperative HD remains unclear. We evaluated the safety and feasibility of a standardized HD protocol in patients undergoing off-pump CABG (OPCAB).

Methods: We retrospectively analyzed 64 HD-dependent patients who underwent elective OPCAB at a single institution between March 2014 and December 2024. The protocol included maintaining a Monday–Wednesday–Friday HD schedule, performing routine HD on Monday morning, conducting OPCAB on Monday afternoon, and resuming HD on postoperative day (POD) 2. Clinical outcomes, unplanned dialysis, and perioperative biochemical changes were assessed.

Results: Seven patients (10.9%) required unplanned renal replacement therapy before the first postoperative HD session for congestive heart failure (n = 3), hyperkalemia (n = 3), or respiratory failure (n = 1). None required additional dialysis after the initial postoperative HD. In-hospital mortality was 3.1%. Postoperative congestive heart failure occurred in 4.7% of patients. Body weight returned to near baseline by POD 7, and serum potassium remained within an acceptable range throughout the perioperative period.

Conclusion: This standardized perioperative HD protocol was feasible for maintenance HD patients undergoing elective OPCAB. However, protocol deviation in 10.9% of patients suggests that further refinement and prospective comparative studies are warranted.

Purpose: Recirculation is a critical issue in veno-venous extracorporeal membrane oxygenation (VV ECMO). We propose a novel method for estimating the recirculation ratio using temporary sweep-gas control.

Methods: A circuit simulating VV ECMO recirculation was constructed by introducing a short circuit between the inlet and outlet of the oxygenator, enabling direct measurement of recirculation flow. Temporary cessation of sweep gas induced decreases in oxygen saturation at the oxygenator inlet (S_preO₂) and outlet (S_postO₂). The ratio of their temporal changes (⊿S_preO₂/⊿S_postO₂) converged to the recirculation ratio, reflecting blood mixing. The early prediction phase was defined as the interval required for oxygen saturation to decrease from 99% to 95% after sweep-gas cessation. The method was validated in an acute porcine model.

Results: In circuit experiments, the relative prediction error was 7.0% ± 5.2%. Early prediction required 3.0 ± 1.0 s when recirculation was ≤50% and 4.1 ± 1.0 s when >50%. In animal experiments, the error was 7.5% ± 4.0%, with times of 10.4 ± 2.8 s for recirculation ≤50% and 27.8 ± 0.5 s for >50%.

Conclusions: The proposed method enables rapid, less invasive prediction of the recirculation ratio and may provide a practical tool for optimizing ECMO management.

Purpose: We investigated the clinical significance of lymphovascular invasion (LVI) in locally advanced lung adenocarcinoma after induction chemoradiotherapy (CRT).

Methods: We retrospectively reviewed patients with completely resected lung adenocarcinoma after induction CRT from 2007 to 2021 at our institution. We evaluated the effects of LVI on recurrence-free survival (RFS) and overall survival (OS).

Results: Fifty-six patients were included. The reasons for induction CRT were superior sulcus tumor (n = 11, 19.6%), direct invasion of other organs (n = 7, 12.5%), bulky N1 (n = 3, 5.4%), and N2 (n = 35, 62.5%). A pathological complete response was observed in 6 patients (10.7%). LVI was present in 14 patients (25.0%) and absent in 42 (75.0%). The LVI-positive group had significantly worse 5-year RFS (7.8% vs. 49.7%, p <0.001) and OS (35.2% vs. 73.5%, p = 0.003) than the LVI-negative group. Multivariate analysis revealed that LVI was a significant prognostic factor for both RFS (hazard ratio [HR], 3.91; 95% confidence interval [CI], 1.64–9.32, p = 0.002) and OS (HR, 5.75; 95% CI, 1.92–17.20, p = 0.002).

Conclusions: LVI can be a poor prognostic factor and an important biomarker for assessing the effectiveness of multimodal treatment in lung adenocarcinoma.

Purpose: This study aimed to compare surgical safety outcomes of uniportal and multiportal video-assisted thoracoscopic surgery (uVATS and mVATS) segmentectomy during institutional adoption, focusing on differences according to lobar location.

Methods: We retrospectively analyzed 117 patients who underwent thoracoscopic segmentectomy between 2019 and 2024 (uVATS, 49; mVATS, 68). Outcomes included intraoperative pulmonary vessel injury and major postoperative complications, along with operative time, blood loss, and length of hospital stay. Inverse probability of treatment weighting was applied, and analyses were performed overall and stratified by lobe.

Results: Pulmonary vessel injury occurred in 12 patients (10.3%), and grade ≥III complications in 10 (8.5%). After adjustment, uVATS showed a higher incidence of vascular injury than mVATS overall (22.8% vs. 5.5%; p = 0.006). No statistically significant differences were observed in upper-lobe segmentectomy. In lower-lobe segmentectomy, uVATS showed higher rates of vascular injury (44.8% vs. 2.2%; p <0.001) and grade ≥III complications (18.8% vs. 0%; p = 0.005).

Conclusions: No statistically significant differences were observed between uVATS and mVATS in upper-lobe segmentectomy. However, during the institutional adoption phase, careful consideration is warranted when performing lower-lobe segmentectomy with uVATS due to a higher incidence of complications related to surgical safety.

Purpose: This study aimed to compare outcomes of the modified wrapping technique (MWT) and supracoronary tube replacement (STR) for isolated ascending aortic aneurysms, focusing on perioperative safety, 5-year survival, and arterial stiffness.

Methods: This retrospective, single-center study included 205 patients undergoing MWT (n = 91) or STR (n = 114) between 2006 and 2019 for isolated ascending aortic aneurysms ≥50 mm or rapidly progressing lesions. A prospective substudy evaluated arterial stiffness using the SphygmoCor system in a matched subgroup of 40 patients. The primary endpoint was 5-year survival; secondary endpoints included perioperative outcomes, prosthetic infection, and hemodynamic indices.

Results: MWT showed significantly shorter cardiopulmonary bypass and aortic cross-clamp times (p <0.0001) and reduced hospital stay (10.5 ± 0.3 vs. 13.5 ± 0.8 days; p = 0.001). In-hospital mortality tended to be lower with MWT (0% vs. 4.4%; p = 0.06). Five-year survival was comparable between groups (88.1% vs. 83.4%; p = 0.17). Prosthetic infection was significantly lower in the MWT group (1.1% vs. 7.0%; p = 0.04). Hemodynamic assessment demonstrated lower pulse wave velocity and aortic augmentation index in the MWT group.

Conclusions: MWT was associated with shorter operative times and lower prosthetic infection rates while maintaining similar early and mid-term survival compared with STR. These findings suggest MWT as a valuable alternative in selected patients.

Purpose: The aim of this study was to evaluate the effectiveness of closed-incision negative pressure wound therapy (ciNPWT) as a prophylactic measure to prevent deep sternal wound infection (DSWI) after surgery.

Methods: A total of 209 patients undergoing isolated coronary artery bypass grafting via median sternotomy were enrolled. The patients were divided into 3 groups according to incisional care. In Group A (n = 63), the wound was covered with sterile gauze dressings alone. In Group B (n = 71), an indwelling subcutaneous drain was placed and the wound was covered with a hydrocolloid dressing. In Group C (n = 75), an indwelling subcutaneous drain was placed and the wound was covered with a ciNPWT device (PICO; Smith & Nephew). The incidence of DSWI occurring within 60 postoperative days was compared among the 3 groups.

Results: There were no significant differences in preoperative, operative, or postoperative variables among the groups. Postoperative DSWI occurred in 11.1% (7/63) of patients in Group A and 5.6% (4/71) of patients in Group B, whereas no patients in Group C developed DSWI.

Conclusions: Immediate application of NPWT was associated with a reduced rate of wound infection. This treatment may represent an effective preventive strategy.

Purpose: Cranial migration of the right middle lobe (RML) after right upper lobectomy may cause bronchial angulation and alter postoperative lung volume distribution. We investigated whether RML fixation techniques affect postoperative lobar volume and pulmonary function.

Methods: This retrospective single-center study included 96 patients who underwent right upper lobectomy for non–small cell lung cancer (2009–2020). Patients were classified into 3 groups: no fixation, normal fixation, and sliding (anterior–caudal) fixation of the RML to the right lower lobe (RLL). Lobar volumes were assessed using 3-dimensional computed tomography volumetry, and postoperative pulmonary function tests were analyzed when available.

Results: Both lower lobes showed significant compensatory expansion, with the RLL demonstrating the largest increase. Overall, RML volume did not change significantly. However, RML volume increased in the normal fixation group (+58.9 ± 78.2 mL) but decreased in the sliding-fixation (−29.0 ± 92.6 mL) and no-fixation groups (−16.9 ± 118.9 mL), with significant differences among groups (p <0.001). Postoperative changes in forced vital capacity and forced expiratory volume in 1 second did not differ among groups, and RML volume change was not correlated with pulmonary function.

Conclusions: Normal RML fixation preserved RML volume after right upper lobectomy, but did not improve postoperative pulmonary function. Further studies are warranted.

Purpose: Although immune checkpoint inhibitor-based perioperative therapy has become the standard for resectable stage IIIA-N2 non-small cell lung cancer (NSCLC), not all patients are eligible for this approach. This study evaluated long-term outcomes of histology-based induction chemoradiotherapy (CRT) followed by surgery.

Methods: This prospective observational study enrolled 48 consecutive patients with pathologically confirmed stage IIIA-N2 NSCLC between April 2010 and May 2025. Patients with squamous cell carcinoma (Sq) received cisplatin/vinorelbine, while those with non-squamous cell carcinoma (non-Sq) received cisplatin/pemetrexed, both with concurrent radiotherapy (50 Gy), followed by surgery.

Results: All 48 patients (25 Sq, 23 non-Sq) completed induction CRT; 45 (93.8%) underwent surgery, with 97.8% achieving complete resection. Median follow-up was 48.8 months. The 5-year overall survival/disease-free survival (DFS) rates were 77.9%/77.3% for Sq and 70.5%/33.7% for non-Sq cohorts. Grade 3/4 toxicities were more frequent in Sq patients (80.0% vs. 21.7%, p <0.001). Exploratory analysis revealed inferior DFS in epidermal growth factor receptor (EGFR)-mutated non-Sq patients, though overall survival remained favorable with subsequent tyrosine kinase inhibitor therapy.

Conclusion: Histology-based induction CRT followed by surgery demonstrated feasibility and favorable outcomes, particularly for Sq and EGFR-negative non-Sq NSCLC. These findings provide a reference for patients ineligible for immune checkpoint inhibitor-based therapy.

Purpose: Aortoesophageal fistula (AEF) after esophagectomy is a rare but catastrophic complication, often occurring after anastomotic leakage and mediastinal contamination. Evidence regarding fatal trajectories and rescue failure points remains limited.

Methods: We performed a retrospective, single-center study among esophageal cancer patients who developed AEF after esophagectomy between 2013 and 2024. Cases were identified from institutional databases and mortality records, followed by manual screening. Clinical course, antecedent complications, diagnostic workup, rescue interventions, and causes of death were summarized descriptively.

Results: Among 5543 esophagectomies, 17 patients (0.31%) developed AEF: 16 fatal (94.1%) and 1 survivor (5.9%). All were male, median age 63 years. Anastomotic leak occurred in 16 patients (94.1%), all with mediastinal infection. Sentinel bleeding preceded hemorrhage in 14 patients (82.4%); the median interval to fatal hemorrhage was 1 day.

Conclusions: Post-esophagectomy AEF is highly lethal. Sentinel bleeding represents a critical intervention window. Prompt recognition and multidisciplinary escalation may enable survival even in high-risk patients.

Purpose: The optimal method of pericardial closure in lung transplantation remains controversial. This study aimed to evaluate the technical feasibility and procedural simplicity of pericardial closure using donor pericardium.

Methods: We retrospectively reviewed 70 adult patients who underwent deceased-donor bilateral lung transplantation with cardiopulmonary bypass or central extracorporeal membrane oxygenation between December 2010 and January 2024 at Kyoto University Hospital. Patients were divided into the Donor pericardium group (n = 21) and the Autologous tissue group (n = 49). Pericardial closure time was assessed as an indicator of procedural simplicity, and postoperative complications within 1 year were descriptively evaluated.

Results: Baseline characteristics did not differ between the groups. Mean pericardial closure time was significantly shorter in the Donor pericardium group than in the Autologous tissue group (13 ± 2.4 vs 19 ± 1.6 min, P = 0.03). No clinically concerning differences in postoperative complications were observed during short- to mid-term follow-up.

Conclusion: Pericardial closure using donor pericardium enables technically simpler and faster closure without apparent short-term safety concerns.

Purpose: Malignant cardiac tumors are rare and have a poor prognosis. Surgical resection is performed for symptom relief and survival benefit, but its efficacy is limited. We reviewed our 20-year single-institution experience with primary and metastatic malignant cardiac tumors.

Methods: We retrospectively reviewed 15 patients who underwent resection for histologically confirmed malignant cardiac tumors between 2006 and 2025. Data included tumor characteristics, resection status, and survival outcomes.

Results: Of 15 patients, 7 (46.7%) had primary tumors (most common: angiosarcoma) and 8 (53.3%) had metastatic lesions. The right atrium was the most frequent site (60.0%). Complete (R0) resection was achieved in only 3 cases (20.0%). Median overall survival (OS) for the cohort was 11 months. Patients with angiosarcoma had particularly poor outcomes (median OS: 5 months). One patient with metastatic thymic carcinoma achieved long-term survival (>15 years) following multimodal therapy. Adjuvant therapy was administered in 7 patients (46.7%). No 30-day postoperative mortality occurred.

Conclusion: Surgical resection of malignant cardiac tumors is feasible with acceptable perioperative safety. Although R0 resection is rarely attainable and long-term outcomes remain poor, particularly for high-grade sarcomas, a multimodal approach is essential to optimize outcomes in selected patients.

Purpose: Silent cerebral infarctions are common after aortic arch surgery; however, the predictive value of preoperative computed tomography (CT)-derived plaque characteristics remains unclear. We investigated the incidence, distribution, and risk factors for new cerebral infarction lesions (NCILs) after total aortic arch replacement (TAR), focusing on low-attenuation plaque (LAP, 0–60 Hounsfield units [HU], a surrogate of lipid-rich vulnerable plaque) burden.

Methods: Among 82 consecutive TAR patients, 41 underwent both pre- and postoperative brain diffusion-weighted magnetic resonance imaging (MRI). Clinical profiles, CT-derived atheroma grade and plaque attenuation, operative details, and outcomes were compared between NCIL-positive and NCIL-negative groups. The primary multivariable model simultaneously included arch atheroma grade and LAP area, adjusted for age and sex.

Results: NCILs were detected in 25/41 patients (61%): 23 silent and 2 symptomatic. All NCILs exhibited embolic imaging features without watershed or hypoperfusion patterns. NCIL-positive patients had significantly greater arch LAP area (63.9 vs. 17.7 mm², p <0.01). On multivariable analysis, arch LAP remained the only independent predictor (OR per 10 mm², 3.01; 95% confidence interval [CI] 1.50–8.75; p = 0.012), whereas atheroma grade was not.

Conclusion: More than half of TAR patients developed MRI-detected, predominantly silent NCILs. Preoperative arch LAP was the sole independent predictor. LAP assessment may refine intraoperative risk stratification and guide tailored neuroprotective strategies.

Purpose: Conventional monitoring of serum creatinine at isolated time points is suboptimal for reflecting disease progression. We therefore evaluated the prognostic value of distinct serum creatinine trajectories for predicting all-cause mortality in this patient population.

Methods: We conducted a retrospective cohort study of elderly patients undergoing cardiac surgery, using data from the Medical Information Mart for Intensive Care database (MIMIC-IV). Kaplan–Meier analysis compared survival outcomes among the identified classes. Multivariable logistic and Cox proportional hazards models determined the independent associations of these trajectories with in-hospital and 1-year all-cause mortality.

Results: A total of 5145 patients undergoing cardiac surgery were included in the analysis. Three distinct creatinine trajectories were identified: low-stable (Class 1), persistent-increase (Class 2), and transient-increase (Class 3). Class 1 had the lowest in-hospital and 1-year mortality rates. Using Class 1 as the reference, Class 2 demonstrated the highest mortality risk, followed by Class 3.

Conclusion: Distinct creatinine trajectory patterns conferred independent prognostic value for postoperative outcomes in elderly patients after cardiac surgery. A persistently high trajectory was independently associated with significantly increased mortality compared to the low-stable trajectory class.

Purpose: Lung resection is a standard treatment for localized lung cancer, but prolonged air leakage is a common complication with health and economic burdens. Interventions such as staplers, sealants, and adjunctive materials are used, yet real-world data describing their utilization remain limited.

Methods: Using a hospital database with claims and discharge summaries from 393 hospitals in Japan, we identified patients undergoing lobectomy, segmentectomy, or partial resection for primary lung cancer between 2015 and 2020. We evaluated intraoperative use of staple-line buttresses, fibrin glue, polyglycolic acid (PGA) sheets, and other materials. Patient characteristics and comorbidities were compared across material-use categories, and the incidence of prolonged postoperative drainage (≥7 days) was assessed.

Results: Among 33094 lobectomy, 5443 segmentectomy, and 8242 partial resection patients, buttress use was uncommon (2.2%, 3.5%, and 6.4%). Patients receiving buttresses or PGA plus fibrin glue had higher prevalences of emphysema and interstitial pneumonia than those in the stapler-only group. Prolonged drainage remained frequent (6.9% in stapler-only vs. 24.8% in buttress among lobectomy patients) and was associated with nearly doubled postoperative in-hospital costs.

Conclusions: Prolonged air leakage remains a major complication following lung resection, associated with clinical and economic burden. This study provided a nationwide overview of real-world utilization patterns of adjunctive materials.

Purpose: The present study reviewed surgical cases of lung cancer associated with cystic airspace (LCCA) and examined the imaging and clinicopathological features of these cases.

Methods: A total of 75 patients with lung cancer associated with cystic airspace, who underwent lung cancer surgery in our hospital between January 2017 and December 2020, were included. We retrospectively analyzed the association between postoperative recurrence of lung cancer and lung cancer associated with the cystic airspace using the Cox proportional hazards model.

Results: Patients with LCCA had a worse prognosis than those with non-LCCA. Furthermore, a univariate analysis showed a significant difference between sex, smoking, differentiation, tumor size, Stage, and LCCA, while a multivariate analysis showed a significant difference between Stage and LCCA. LCCA cases were classified into four categories, as reported in a previous study. Types I and III showed more adenocarcinomas, while Type IV tended to show squamous cell carcinomas.

Conclusions: LCCA has a poor prognosis. It is often difficult to determine which of the T factors of the TNM classification are applied. Therefore, further studies are needed to accumulate more LCCA cases.

Purpose: A decrease in peripheral basophil count has recently been suggested as a potential marker of poor prognosis in malignancies. This study aimed to determine the optimal cutoff value for basophil count and assess its clinicopathological and prognostic significance in esophageal squamous cell carcinoma (ESCC).

Methods: We retrospectively analyzed 194 patients with ESCC (157 men, 37 women; mean age, 67 years [range, 34–88]) who underwent curative surgery between 2010 and 2020, including 100 who received neoadjuvant chemotherapy. Receiver-operating characteristic curve analysis identified an optimal basophil cutoff value of 17.4/μL. Patients were divided into low- and high-basophil groups, and clinicopathological factors and prognosis were assessed using univariate and multivariate analyses.

Results: Low-basophil counts were significantly correlated with low neutrophil counts but not with C-reactive protein level. Multivariate analysis to predict overall survival identified deep invasion, elevated C-reactive protein, and low-basophil count as independent predictors of a poor prognosis (P <0.05).

Conclusion: Low preoperative basophil count is an independent adverse prognostic factor in ESCC. As basophil count was not correlated with C-reactive protein, it may provide prognostic value beyond conventional inflammation-based markers and could represent a simple, low-cost biomarker to aid risk stratification in the preoperative setting.

Purpose: Research regarding Custodiol’s safety in minimally invasive mitral valve repair remains limited in Asian populations. We compared Custodiol in minimally invasive mitral valve repair to repetitive cold blood cardioplegia in open mitral valve repair.

Methods: We retrospectively evaluated 98 consecutive patients who underwent minimally invasive mitral valve repair with Custodiol and 70 consecutive patients who underwent open mitral valve repair with repetitive cold blood cardioplegia at our institution between January 2015 and December 2024. The primary endpoints were creatine kinase-myocardial band (MB) levels and left ventricular ejection fraction determined by echocardiography pre- and post-surgery.

Results: Maximum creatine kinase-MB levels within 48 h post-surgery were significantly lower in the minimally invasive group than in the open repair group, both in the overall cohort (45.0 vs. 60.7 U/L; p <0.001, respectively) and after excluding patients who underwent Maze procedure or pulmonary vein isolation (42.4 vs. 50.0 U/L; p = 0.009, respectively). Left ventricular ejection fraction pre- and post-surgery was comparable between the minimally invasive and open repair groups (72% vs. 69%; p = 0.426 and 59% vs. 60%; p = 0.204, respectively).

Conclusion: Custodiol during minimally invasive mitral valve repair provides myocardial protection comparable to repetitive cold blood cardioplegia in open mitral valve repair.

Purpose: Central airway adenoid cystic carcinoma (CAACC) is a rare malignancy lacking a standard treatment approach and often precluding complete resection. This study assessed the surgical outcomes of patients with CAACC treated at a single institution.

Methods: We retrospectively reviewed patients who underwent surgical resection for CAACC between September 2013 and August 2021.

Results: Eight patients (mean age: 51.5 years) were included. Tumor locations were bronchus (n = 1), trachea (n = 4), carina and bronchus (n = 2), and carina and trachea (n = 1). Surgical procedures included sleeve lobectomy (n = 1), tracheal resection (n = 4), sleeve pneumonectomy (n = 2), and carinal resection with reconstruction (n = 1). Preoperative radiation and bronchoscopic tumor resection were performed in 1 patient each. One patient died from a postoperative tracheoinnominate artery fistula. Major complications included recurrent laryngeal nerve palsy (n = 3). Adjuvant therapy was provided for positive or uncertain margins. During a median follow-up of 6 years, 2 patients developed recurrence but remained alive at the last follow-up. The 5-year overall survival rate was 72.9%.

Conclusion: Surgical resection with airway reconstruction and adjuvant therapy can offer long-term disease control in CAACC, though life-threatening complications warrant careful consideration.

Purpose: This study aimed to evaluate sex-based differences in the clinical characteristics, aortic anatomy, surgical strategies, and outcomes of patients undergoing emergency surgery for acute Stanford type A aortic dissection (AAAD).

Methods: We retrospectively analyzed 148 consecutive patients (82 males and 66 females) who underwent surgery for AAAD at a single center. We compared their backgrounds, entry tear locations, operative procedures, and postoperative outcomes. Kaplan–Meier analysis assessed long-term survival and freedom from re-intervention.

Results: Female patients were significantly older than male patients, more likely to have ascending aortic entry tears, and more often treated by hemiarch replacement. Male patients underwent total arch replacement more frequently because of arch or distal entry tears and had a higher incidence of iliac artery involvement, indicating more extensive distal dissection. In-hospital mortality, major postoperative complications, long-term survival, and freedom from re-intervention showed no significant sex-based differences.

Conclusion: In female patients, the predominance of ascending entry tears allows less extensive surgery without compromising outcomes. Therefore, when dissection patterns are suitable, emergent surgery is appropriate even in elderly female patients.

Purpose: This study aimed to assess perioperative features, early postoperative outcomes, and mid-term cardiac function in children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) undergoing surgical repair.

Methods: A retrospective review of 23 patients treated surgically between 2007 and 2023 was conducted. Patients were categorized into infants (<1 year) and older patients (>1 year). Clinical, operative, and echocardiographic data were analyzed, including left ventricular ejection fraction (LVEF) and mitral regurgitation (MR). Follow-up evaluations were performed at 1 and 6 months postoperatively.

Results: The median age at surgery was 9 months. Early mortality occurred in 17.4%, with no late deaths during follow-up. Preoperative LVEF was significantly lower in infants than in older patients (p = 0.013). Among 19 survivors, LVEF improved markedly by 1 month and normalized in all patients by 6 months. MR was present in 89.5% preoperatively, with 47.3% showing moderate to severe grades. At 6 months, MR improved in most cases, with only 2 patients exhibiting residual moderate regurgitation and no severe cases.

Conclusions: ALCAPA is a rare but surgically correctable condition. Early surgical intervention leads to significant recovery of ventricular function and regression of MR within the first 6 postoperative months.

Purpose: The internal thoracic artery (ITA) has shown increased production of nitric oxide, which has beneficial effects on ventricular remodeling, among conduits of coronary artery bypass grafting (CABG). However, little is known about the impact of bilateral ITA strategy on postoperative left ventricle (LV) reverse remodeling as compared with single ITA, especially in patients with severely impaired LV function.

Methods: We retrospectively reviewed 126 propensity-matched patients with advanced ischemic cardiomyopathy (ICM) (left ventricular ejection fraction <40%) who underwent isolated multiple CABG utilizing bilateral (BITA group; n = 65) or single (SITA group; n = 61) ITA. The primary endpoint was postoperative reduction in the indexed left ventricular end-systolic volume index (LVESVI). Baseline covariates were adjusted with propensity score-matching.

Results: At baseline, there were no intergroup differences in LVESVI (78 vs. 78 ml/m², P = 0.93) and EuroSCORE II score (3.0% vs. 2.8%, P = 0.70). At 6 months post-surgery, the BITA group reduced LVESVI to a greater degree than the SITA group (−33% vs. −17%, P <0.01), resulting in significantly smaller postoperative LVESVI (49 vs. 63 ml/m², P = 0.03). Multivariable analysis showed that CABG with BITA (P = 0.011) was associated with postoperative LV reverse remodeling.

Conclusion: In patients with ICM undergoing CABG, the in situ BITA strategy was associated with greater reductions in postoperative LV volume.

Purpose: The superior segment (S6) may differ from the basal segments (BSs) in lymphatic spread, affecting surgical strategy and mediastinal lymph node dissection (LND). We aimed to define lymphatic spread patterns and to guide surgical strategy in S6 non-small cell lung cancer (NSCLC).

Methods: We reviewed 375 patients with cT1a–cT1c N0 lower-lobe NSCLC (S6, 168; BS, 207) who underwent segmentectomy or lobectomy (2012–2024). We analyzed nodal metastasis and recurrence by station.

Results: Segmentectomy was more frequent in S6 than in BS. pN1 and pN2 incidence was 8.3% and 2.4% in S6 and 4.3% and 6.8% in BS, respectively. In S6, pN2 metastases were single-station with N1, with no inferior mediastinal involvement. S6 nodal recurrences were confined to #4L/#4R and occurred outside the LND field. In BS, skip pN2 was more frequent and nodal recurrences occurred at #7 within the field.

Conclusion: In clinical stage IA S6 NSCLC, nodal events occurred in the superior mediastinal stations. All pN2 were single-station with N1, and all nodal recurrences occurred after lobe-specific mediastinal LND. Management should follow intraoperative N1 assessment: if negative, S6 segmentectomy without mediastinal LND; if positive, lobectomy with superior mediastinal and subcarinal LND, omitting inferior mediastinal nodes unless specifically suspected.

Purpose: Pulmonary vein stump thrombus (PVST) is a relatively common complication after left upper lobectomy that can cause vital organ embolism. We previously found that patients with PVST on postoperative day 7 show risky hemodynamic features around the pulmonary vein stump on 4-dimensional (4D) flow magnetic resonance imaging (MRI), which may contribute to thrombus development. However, it remains unclear whether such hemodynamics persist later.

Methods: Eleven patients who underwent left upper lobectomy for lung cancer received 4D flow MRI on postoperative day 7 and again after over 3 months. Hemodynamic parameters were used to classify each case as risky or non-risky for PVST.

Results: According to a total of 24 examinations in 11 patients, 7 were classified as risky and 17 as non-risky. PVST developed in 6 patients during various postoperative phases, and all PVST cases developed under the risky conditions. Furthermore, PVST did not develop under non-risky conditions, suggesting that our risk assessment is valid as a predictive marker for PVST.

Conclusion: Our results suggest that late postoperative hemodynamic assessments, as well as early postoperative assessments, are useful for identifying patients at high risk of PVST. A late postoperative hemodynamic assessment may contribute to determining when to discontinue anticoagulants.

Purpose: Surgery for Jehovah’s Witness patients with Stanford type A aortic dissection (TAAD) carries a high surgical risk, and few reports have examined outcomes in this patient population. This study evaluated perioperative outcomes of surgery for TAAD in Jehovah’s Witness patients.

Methods: Eight Jehovah’s Witness patients who underwent surgery for TAAD at our institution between February 2016 and January 2025 were retrospectively reviewed. No patients were receiving antiplatelet or anticoagulant therapy at the time of surgery. Preoperative characteristics, operative data, and postoperative outcomes were assessed.

Results: Emergency ascending aortic replacement was performed in 6 patients, while the 2 patients who underwent elective surgery due to a chronic course or thrombosed false lumen received total or partial arch replacement. Both elective cases received preoperative iron supplementation. The median postoperative nadir hemoglobin was 9.2 (interquartile range, 6.8–9.6) g/dL. One patient died, one was transferred to rehabilitation, and 6 patients (75.0%) were discharged home without major complications.

Conclusions: Perioperative outcomes of surgery for TAAD in Jehovah’s Witness patients were favorable. Proper surgical timing and preoperative management are essential to achieving satisfactory results. Further investigation with a larger cohort and longer follow-up is warranted.

An 85-year-old bedridden woman (modified Rankin Scale 5) presented with a contained rupture of an acute retrograde aortic dissection (Type B0,7). Because open surgery was prohibitive due to severe frailty, an emergent total endovascular repair was performed using single-branch, retrograde in situ branched stent grafting (RIBS). Two conformable GORE TAG devices established a Zone 1 seal, and the left common carotid artery was preserved by in situ needle fenestration using a percutaneous transhepatic gallbladder drainage needle and bridged with a VIABAHN VBX stent. To limit embolic risk, cerebral blood flow was transiently interrupted by manual right carotid compression, direct left carotid clamping, and left subclavian balloon occlusion. Operative time was 114 minutes, and the postoperative course was uneventful without neurological deficits. One-year computed tomography showed favorable aortic remodeling and no endoleak. Single-branch RIBS may offer an immediate, off-the-shelf salvage option for high-risk patients when open repair is not feasible.

Giant cystic anterior mediastinal tumors pose a significant challenge for minimally invasive surgery because of limited working space and the risk of cyst rupture. A 26-year-old woman presented with a large anterior mediastinal cystic tumor strongly suggestive of a benign lesion on imaging. To secure an adequate operative field and reduce the risk of intraoperative rupture, computed tomography–guided transmediastinal drainage was performed preoperatively. Tumor volume reduction improved surgical exposure and maneuverability and reduced the risk of rupture, enabling robot-assisted thoracoscopic surgery. Despite dense inflammatory adhesions between the tumor and surrounding tissues, precise dissection was achieved with robotic assistance, allowing complete tumor resection without rupture. This case suggests that a staged strategy combining preoperative drainage and robotic surgery may represent a safe and effective minimally invasive approach for selected patients with giant benign mediastinal cystic tumors.

A residual false lumen after type A aortic dissection repair may rarely serve as an embolic route to the cerebral circulation. A woman in her 60s underwent ascending aortic replacement for Stanford type A aortic dissection, leaving a residual patent dissection involving the supra-aortic branches and the descending aorta. Despite receiving anticoagulant and antiplatelet therapies, the patient developed recurrent multifocal cerebral infarctions. Transesophageal echocardiography (TEE) demonstrated an entry tear in the descending aorta communicating from the true lumen to the false lumen. Flow became markedly stagnant toward the proximal false lumen, with thrombus-like echogenic material. Four-dimensional computed tomography (4DCT) confirmed delayed retrograde flow ascending within the false lumen toward the arch. Total arch replacement was performed to eliminate the suspected embolic route. Intraoperative findings confirmed thrombotic material within the false lumen. No recurrent cerebral infarctions were observed postoperatively.

Donor coronary artery disease (CAD) can lead to the discard of otherwise suitable hearts, although selected focal lesions may be treated with concomitant revascularization. We report orthotopic heart transplantation in a 52-year-old man with end-stage ischemic cardiomyopathy and previous coronary artery bypass grafting using a donor heart in which coronary computed tomography angiography showed severe proximal left anterior descending artery (LAD) stenosis with calcified plaque. Before recipient cardiectomy, the recipient’s previously constructed, patent left internal mammary artery (LIMA)-to-LAD graft was carefully mobilized, preserved as an arterial conduit, and repurposed for donor-heart revascularization. After implantation, the salvaged recipient LIMA was anastomosed to the donor LAD distal to the stenosis. Transit-time flow measurement confirmed satisfactory graft function. The patient recovered uneventfully, with preserved biventricular function and angiographic LIMA–LAD patency. This case highlights the technical feasibility of reusing a pre-existing recipient LIMA graft to permit transplantation of a donor heart with focal CAD.

Stapled bullectomy is a safe procedure for primary spontaneous pneumothorax (PSP). Early infection-driven staple-line failure with metalloptysis after bullectomy for PSP is rare. A 21-year-old man underwent video-assisted thoracoscopic bullectomy for persistent right PSP. The staple lines were reinforced with polyglycolic acid sheets. The early postoperative course was uneventful, but the patient developed fever, cough, and purulent sputum on postoperative day 21. Computed tomography demonstrated fluid-filled cavitary lesions along the staple lines in the right upper and lower lobes, with partial staple-line disruption. Sputum cultures yielded oral commensals, and an acute lung abscess associated with staple-line failure was diagnosed. Antibiotic therapy was initiated, and he expectorated several surgical staples. The abscess resolved with conservative treatment. This case suggests that acute infection along pulmonary staple lines can lead to staple-line failure and metalloptysis even after routine bullectomy. Persistent postoperative fever or purulent sputum should prompt careful evaluation for staple-line–associated infection.

Durvalumab maintenance therapy following chemoradiotherapy is the standard treatment for patients with unresectable stage III non–small-cell lung cancer. Immune checkpoint inhibitors can alter host immunity, potentially amplifying inflammatory responses during opportunistic infections. We report a rare case of rapidly progressive destroyed lung caused by invasive pulmonary aspergillosis during durvalumab therapy, which was successfully managed with salvage pneumonectomy. A 53-year-old man with locoregionally recurrent lung adenocarcinoma received chemoradiotherapy followed by durvalumab treatment. Invasive pulmonary aspergillosis developed on day 74. Despite intensive antifungal therapy and corticosteroid administration, the right lung developed extensive liquefactive necrosis beyond the irradiated field within 5 weeks. Given the risk of fatal hemoptysis and sepsis, an emergency right pneumonectomy was performed. The frozen hilum required intrapericardial vascular control and reinforcement of the bronchial stump. Recovery was uneventful, and pathological examination confirmed aspergillosis without residual malignancy. Prompt recognition of medical refractoriness and timely surgery are critical for survival.

Primary cardiac intimal sarcoma is an extremely rare, high-grade malignancy characterized by rapid progression and high early recurrence rates. We report the case of a 28-year-old male who underwent emergency resection for a large left atrial intimal sarcoma (10 × 8 cm). Follow-up imaging at 6 months revealed a 15-mm recurrent tumor infiltrating the left atrial septum, despite an initially stable recovery. We prioritized radical resection over surgical risk, given the patient’s youth and the aggressive behavior of the tumor. Therefore, a “Commando” procedure consisting of radical tumor resection, double valve replacement, and reconstruction of the intervalvular fibrosa using the Manouguian technique was performed. Histopathological examination confirmed recurrent intimal sarcoma with negative surgical margins. Despite its high invasiveness, the Commando procedure is viable for primary treatment for recurrent cardiac intimal sarcomas in young patients. Aggressive surgical reconstruction remains the only viable option to improve the prognosis of this otherwise fatal malignancy.

Tracheomediastinal fistula is a rare but potentially life-threatening complication associated with malignant lymphoma. We report a case of spontaneous closure of a tracheomediastinal fistula that developed after chemotherapy for mediastinal diffuse large B-cell lymphoma (DLBCL). A 70-year-old man presented with airway compression caused by a large mediastinal tumor. After airway stabilization with a Dumon Y stent and subsequent R-CHOP chemotherapy, the tumor markedly regressed. Following stent removal, a fistula developed in the anterior tracheal wall, communicating with a necrotic mediastinal space. Because no clinical or laboratory signs of mediastinitis were observed, conservative management without antibiotics or invasive intervention was adopted. The fistula gradually decreased in size and closed completely within 10 weeks. This case suggests that tracheomediastinal fistulas without mediastinitis may be managed conservatively under careful observation. Treatment strategies should be individualized based on anatomical location and the presence or absence of infection.

Post-tuberculosis airway stenosis can cause fixed cicatricial narrowing and long-term disability. We report a female patient with recurrent upper tracheal restenosis despite 2 prior resections, who presented decades later with respiratory failure; intubation was impossible, necessitating emergency tracheostomy. Imaging and bronchoscopy revealed pinhole stenosis near the second tracheal ring and left main bronchial stenosis with a destroyed left lung. The patient remained tracheostomy-dependent and aphonic after infection control. Because repeat resection was high-risk and endoscopic stent delivery was infeasible, a Dumon silicone stent was inserted via transcervical longitudinal tracheotomy under direct vision. Airway patency and phonation improved, and follow-up showed a stable stent without major complications. This open approach may serve as a salvage surgery when endoscopic delivery is impossible.

Interrupted aortic arch (IAA) is a rare congenital anomaly usually diagnosed in infancy and associated with intracardiac defects, making survival into adulthood without repair exceptional. We report the case of a 62-year-old woman with longstanding hypertension who presented with progressive dyspnea and dysphagia. Computed tomography angiography identified a type B IAA associated with a giant 96-mm aneurysm arising from an aberrant retroesophageal artery connecting the right subclavian artery to the descending thoracic aorta, without associated cardiac abnormalities. Surgical management consisted of isolated resection of the aneurysmal segment and placement of a 14-mm Dacron graft, without reconstruction of the aortic arch given the patient’s age and stable hypertension. The postoperative course was uneventful, and follow-up imaging showed stable repair with complete symptom resolution. This case highlights the possibility of long-term survival without restoration of normal aortic anatomy, and suggests that a tailored, complication-focused surgical approach may be appropriate in selected adult patients.

Giant cell tumor of bone (GCTB) rarely metastasizes, but pulmonary lesions pose therapeutic challenges. We report a woman in her 30s who developed multiple bilateral lung nodules 3.5 years after distal ulna GCTB resection and local recurrences. Denosumab 120 mg every 4 weeks was given for 2.5 years, producing shrinkage, calcification, and stability. Staged, palpation-guided thoracoscopic wedge resections (8 left, 5 right) achieved complete macroscopic clearance with negative margins. Histology showed spindle-cell proliferation with woven bone and depletion of giant cells; H3.3 G34W immunostaining confirmed metastatic GCTB. She remains recurrence-free 7 years and 5 months after metastasectomy. Denosumab displayed site-specific surgical implications—unfavorable at the primary bone site due to peritumoral sclerosis, yet advantageous in the lung where it clarifies margins and enables parenchyma-sparing R0 resection. A surgery-forward strategy that uses time-limited denosumab as a bridge to meticulous thoracoscopic metastasectomy may secure durable control in multifocal pulmonary GCTB.