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Purpose For severe lung injuries or acute respiratory distress syndrome that occurs during critical care due to trauma, extracorporeal membrane oxygenation (ECMO) may be used as a salvage treatment. This study aimed to describe the experiences at a single center with the use of ECMO in trauma patients. Methods We enrolled a total of 25 trauma patients who were treated with ECMO between January 2015 and December 2019 at a regional trauma center. We analyzed and compared patients’ characteristics between survivors and non-survivors through a medical chart review. We also compared the characteristics of patients between direct and indirect lung injury groups. Results The mean age of the 25 patients was 45.9±19.5 years, and 19 patients (76.0%) were male. The mean Injury Severity Score was 26.1±10.1. Ten patients (40.0%) had an Abbreviated Injury Scale (AIS) 3 score of 4, and six patients (24.0%) had an AIS 3 score of 5. There were 19 cases (76.6%) of direct lung injury. The mortality rate was 60.0% (n=15). Sixteen patients (64.0%) received a loading dose of heparin for the initiation of ECMO. There was no significant difference in heparin use between the survivors and non-survivors (70% in survivors vs. 60% in non-survivors, p=0.691). When comparing the direct and indirect lung injury groups, there were no significant differences in variables other than age and ECMO onset time. Conclusions If more evidence is gathered, risk factors and indications will be identified and we expect that more trauma patients will receive appropriate treatment with ECMO.

Objective To compare the diagnostic performance of contrast-enhanced radial T1-weighted gradient-echo 3-tesla (3T) magnetic resonance imaging (MRI) and computed tomography (CT) for the detection of visceral pleural surface invasion (VPSI). Visceral pleural invasion by non-small-cell lung cancer (NSCLC) can be classified into two types: PL1 (without VPSI), invasion of the elastic layer of the visceral pleura without reaching the visceral pleural surface, and PL2 (with VPSI), full invasion of the visceral pleura. Materials and methods Thirty-three patients with pathologically confirmed VPSI by NSCLC were retrospectively reviewed. Multidetector CT and contrast-enhanced 3T MRI with a free-breathing radial three-dimensional fat-suppressed volumetric interpolated breath-hold examination (VIBE) pulse sequence were compared in terms of the length of contact, angle of mass margin, and arch distance-to-maximum tumor diameter ratio. Supplemental evaluation of the tumor-pleura interface (smooth versus irregular) could only be performed with MRI (not discernible on CT). Results At the tumor-pleura interface, radial VIBE MRI revealed a smooth margin in 20 of 21 patients without VPSI and an irregular margin in 10 of 12 patients with VPSI, yielding an accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and F-score for VPSI detection of 91%, 83%, 95%, 91%, 91%, and 87%, respectively. The McNemar test and receiver operating characteristics curve analysis revealed no significant differences between the diagnostic accuracies of CT and MRI for evaluating the contact length, angle of mass margin, or arch distance-to-maximum tumor diameter ratio as predictors of VPSI. Conclusion The diagnostic performance of contrast-enhanced radial T1-weighted gradient-echo 3T MRI and CT were equal in terms of the contact length, angle of mass margin, and arch distance-to-maximum tumor diameter ratio. The advantage of MRI is its clear depiction of the tumor-pleura interface margin, facilitating VPSI detection.

BACKGROUND: Pneumothorax refers to the abnormal presence of air in the thoracic cavity. Pulmonary emphysema (PE) is often detected during computed tomography (CT), one of the radiological investigations used to diagnose pneumothorax and devise treatment plans in former or current smokers who present with pneumothorax. However, there are few reports that describe the recurrence rate and risk factors associated with recurrence in patients with PE and pneumothorax. METHODS: This study retrospectively cross-sectional analyzed the medical records of 164 patients diagnosed with their first episode of secondary spontaneous pneumothorax and admitted to a tertiary care hospital, between March 2013 and February 2019. The CT scans of 98 patients revealed PE, and 49 patients of those underwent pulmonary function tests (PFTs) after the resolution of pneumothorax. Risk factors for recurrence were analyzed using Cox proportional hazard regression. RESULTS: All the subjects were male and former or current smokers, with a median age of 72 years. Thirty-seven (75.5%) patients were treated with tube thoracostomy alone, whereas 12 (24.5%) patients underwent chemical pleurodesis via chest tube or video-assisted thoracoscopic surgery. After recovery from pneumothorax, these patients underwent PFT within a median time period of 5.8 months. Median forced vital capacity and forced expiratory volume in 1 second (FEV(1)) were 3.02 L (91% predicted) and 1.58 L (67% predicted), respectively. In the current study, the recurrence rate of pneumothorax was observed to be 30.6%, within a median time period of 12.4 months. In multivariable-adjusted analysis, decreased FEV(1) was observed to be significantly higher in the patients who exhibited recurrence of pneumothorax than in those who did not (adjusted hazard ratio, 0.408; P=0.025). CONCLUSIONS: In patients with PE and pneumothorax, PFT, performed after recovery, could be a useful test for predicting the recurrence of pneumothorax.

Interferon (IFN)-β and/or tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) secreted by adipose tissue-derived mesenchymal stem cells (ASCs) have been proposed as key mechanistic factors in anti-cancer efficacy in lung cancer and breast cancer cells, where they act through paracrine signaling. We hypothesized that IFN-β and TRAIL produced by ASCs suppress proliferation of hepatocellular carcinoma cells (HCCs). The present study evaluated the anti-cancer effects of ASCs on HCCs in vitro. We found that indirect co-culture with ASCs diminished growth of Huh7 hepatocellular carcinoma cells with increased protein levels of p53/p21 and phosphorylated STAT1 (pSTAT1), without apoptosis. Treatment with ASC-conditioned medium (ASC-CM) also decreased growth of Huh7 cells through elevated p53/p21 and pSTAT1 signaling. ASC-CM-mediated inhibition of cell growth was neutralized in Huh7 cells treated with anti-IFN-β antibody compared to that in ASC-CM-treated Huh7 cells incubated with an anti-TRAIL antibody. Treatment with JAK1/JAK2 inhibitors recovered inhibition of growth in Huh7 cells incubated in ASC-CM or IFN-β via down-regulation of pSTAT1/p53/p21. However, treatment of IFN-β resulted in no alterations in resistance of Huh7 cells to TRAIL. Our findings suggest that ASCs decrease growth through activated STAT1-mediated p53/p21 by IFN-β, but not TRAIL, in Huh7 cells.

Iatrogenic vascular injuries may occur during venipuncture, arterial cannulation, or catheterization procedures. Brachial arteriovenous fistula (AVF) resulting from antecubital vascular access is rare and develops slowly. We report the case of an 18-year-old man who had developed iatrogenic brachial AVF. He had a history of several venipunctures in the left arm at the age of 10 months. Doppler ultrasonography and computed tomographic angiography were used to establish a diagnosis of brachial AVF, and surgical correction of the AVF was performed. As our case indicates, delayed surgery can be considered as a treatment option and may be associated with a decreased risk of vascular complications in the management of iatrogenic brachial AVF in infants.

Thoracic surgery using CO2 insufflation maintains closed-chest one-lung ventilation (OLV) that may provide the necessary heart–lung interaction for the dynamic indices to predict fluid responsiveness. We studied whether pulse pressure variation (PPV) and stroke volume variation (SVV) can predict fluid responsiveness during thoracoscopic surgery. Forty patients were enrolled in the study. OLV was performed with a tidal volume of 6 mL/kg at a positive end-expiratory pressure of 5 cm H2O, while CO2 was insufflated to the contralateral side at 8 mm Hg. Patients whose stroke volume index (SVI) increased ≥15% after fluid challenge (7 mL/kg) were defined as fluid responders. The predictive ability of PPV and SVV on fluid responsiveness was investigated using the area under the receiver-operator characteristic curve (AUROC), which was also assessed according to the right or left lateral decubitus position considering the intrathoracic location of the right-sided superior vena cava. AUROCs of PPV and SVV for predicting fluid responsiveness were 0.65 (95% confidence interval 0.47–0.83, p = 0.113) and 0.64 (95% confidence interval 0.45–0.82, p = 0.147), respectively. The AUROCs of indices did not exhibit any statistical significance according to position. Dynamic indices of preload cannot predict fluid responsiveness during one-lung ventilation with CO2 gas insufflation.

Purpose Pediatric thoracic trauma differs from those of adult in terms of the small anatomy and rapid tissue recovery. Therefore, it is important to know the characteristics of the pediatric thoracic trauma to improve treatment results. In addition, this study examined the changes in pediatric thoracic trauma features and results from the establishment of a level 1 regional trauma center. Methods Data of 168 patients’ ≤ 15 years old diagnosed with thoracic trauma between 2008 and 2019 were retrospectively analyzed. Results Pedestrian traffic accidents were the most common cause of chest injury. The average injury severity score was 17.1 ± 12.4 and the average pediatric trauma score was 5.6 ± 4.1. Lung contusion was the most common in 134 cases. There were 48 cases of closed thoracostomy. There was one thoracotomy for cardiac laceration, one case for extracorporeal membranous oxygenation, and six cases for embolization. Of all, 25 patients died, providing a mortality rate of 14.9%. In addition, independent risk factors of in-hospital mortality were hemopneumothorax and cardiac contusion. Since 2014, when the level 1 regional trauma center was established, more severely injured thoracic trauma patients came. However, the mortality was similar in the two periods. Conclusions Understanding the clinical features of pediatric thoracic trauma patients can help in efficient treatment. In addition, as the severity of pediatric thoracic trauma patients has increased due to the establishment of the regional trauma center, so pediatric trauma center should be organized in regional trauma center to improve the outcomes of pediatric thoracic trauma.

Background The objective of this study was to analyze the differences in clinical presentation and characteristics with regard to diaphragmatic injury between blunt trauma patients with severe low rib fractures and those without severe low rib fractures. Methods The medical records of all patients with diaphragmatic injuries who were surgically treated at this level I trauma center, between January 2004 and December 2016 were reviewed. Patient notes, radiologic findings, and operative reports were evaluated. All of the diaphragmatic injuries were confirmed based on the operative findings. Rib fracture with displacement between the ends of the fracture of more than half the width of the fractured rib on computed tomography was classified as ‘severe rib fracture'. Patients were categorized into 2 groups and analyzed: those who had more than one severe rib fracture in low ribs on the ipsilateral side of the diaphragm injury (Severe group), and those with no severe rib fracture (Non-severe group). Results Delayed diagnosis of diaphragmatic injury was more frequent in the Severe group than in the Non-severe group (81.8% vs 36.8%, p -value = 0.026). With regard to initial indications for operation, intrathoracic visceral herniation was more frequent in the Non-severe group (78.9% vs 18.2%, p -value = 0.002), while hemothorax was more frequent in the Severe group (63.6% vs 5.3%, p -value = 0.001). Central type diaphragmatic laceration was more frequent in the Non-severe group than in the Severe group (78.9% vs 18.2%, p -value = 0.002). The diameter of diaphragmatic injury was larger in the Non-severe group than in the Severe group (9.70 ± 4.10 cm vs 4.80 ± 3.60 cm, p -value = 0.004). Conclusion The results of this study imply that a low threshold for thoracotomy or laparotomy should be considered in blunt trauma patients with severe low rib fractures for the purpose of hidden diaphragmatic injury detection and management.

Background Since anatomical lung resection by video-assisted thoracoscopic surgery (VATS) was first introduced, VATS has played a major role in lung cancer. However, conversion to thoracotomy is a major concern because an unexpected thoracotomy increases the risk of potentially adverse outcomes. Therefore, we compared patients who were and were not converted to thoracotomy and identified the risk factors for thoracotomy conversion. Methods Between January 2005 and December 2013, 69 of 1,110 VATS lobectomies for lung cancer required an unexpected conversion to thoracotomy. Each converted patient was individually matched to 3 randomly selected nonconverted patients based on date of operation, type of operation, and pathologic stage. Results The most common cause of conversion was fibrocalcified lymph nodes, found in 28 patients (40.6%), followed by vascular injury in 20, tumor invasion or extension in 11, pleural adhesion in 5, incomplete interlobar fissure in 3, and failure of single-lung ventilation in 2. The differences in overall postoperative complications and in-hospital deaths were not significant; however, respiratory complications were significantly more common in the conversion group ( p = 0.012). The independent risk factors for conversion were age 65 years and older, forced expiratory volume in 1 second of less than 1.8 L, and the presence of fibrocalcified lymph nodes on preoperative chest computed tomography. Conclusions Unexpected conversion to thoracotomy during VATS lobectomy in lung cancer does not appear to increase overall surgical morbidity and mortality. However, with high-risk patients, the surgeon requires careful selection for VATS candidate. Also, if necessary, the decision to convert must be made promptly to reduce possible critical respiratory complications.

Closed tube thoracostomy is often used to evacuate a primary spontaneous pneumothorax (PSP). Occasionally, this procedure is complicated by placement of the chest tube location in the fissural area instead of pleural space. There is a paucity of studies on outcomes according to chest tube placement. As such, we investigated outcomes of chest tube placement in fissural versus pleural area in closed thoracostomy for PSP. Patients between 14 and 65 years of age who had been treated with chest tube insertion to evacuate PSP were selected based on retrospective review of medical records. Patients selected for this study received chest tube placement at either the fissural or pleural spaces. Those with pre-existing lung disease or those transferred into our hospital after closed thoracostomy were excluded. Of the 255 patients with PSP treated with chest tube insertion, 172 patients were enrolled in this study. Twenty-nine (16.9%) had fissural tube placement and 143 (83.1%) had pleural tube placement. A higher proportion of patients in the fissural versus pleural group required additional chest tube insertion (20.7% vs 4.9%, P = 0.010, respectively). There was no significant difference in body mass index, smoker status, symptom duration, number of episodes, post-thoracostomy complications, need for subsequent management, and duration of hospitalization in either group. In closed thoracostomy for PSP, there is a higher chance of tube dysfunction when the chest tube is positioned at fissural area as compared with the pleural space.

Cardiac rupture following blunt thoracic trauma is rarely encountered, since it commonly causes death at the scene. With advances in critical care, blunt cardiac rupture has been successfully treated with well-organized team approach including an emergency physician, anesthesiologist, and cardiac surgeon. We encountered a patient with blunt cardiac rupture of the junction of the superior vena cava and right atrium that extended 7 cm to the right ventricular junction. The patient was successfully resuscitated after a closed thoracostomy and pericardiocentesis with fluid loading. Cardiac injury was repaired via mid-sternotomy without cardiopulmonary bypass. The patient recovered without complications and was discharged on the 7th day after surgery.

Blunt abdominal trauma may cause peripheral vascular injuries. However, blunt abdominal trauma rarely results in injuries to the external iliac and common femoral arteries, which often stem from regional bone fractures. Here, we present the case of a patient who had experienced trauma in the lower abdominal and groin area three months before presenting to the hospital, but these injuries did not involve bone fractures and had been managed conservatively. The patient came to the hospital because of left lower leg claudication that gradually became severe. Computed tomography angiography confirmed total occlusion of the external iliac and common femoral arteries. The patient underwent femorofemoral bypass grafting and was discharged uneventfully.

Vacuum-assisted closure therapy is an alternative method for a massive subcutaneous emphysema treatment. It is easily applicable and shows rapid effectiveness in massive subcutaneous emphysema, intractable with chest tube drainage.

Chest drainage systems are usually composed of chest tube and underwater-seal bottle. But this conventional system may restrict patients doing exercise and give clinicians obscure data about when to remove tubes because there is no objective indicator. Recently developed digital chest drainage systems may facilitate interpretation of the grade of air leak and make it easy for clinicians to decide when to remove chest tubes. In addition, with combination of wireless internet devices, monitoring and managing of drainage system distant from the patient is possible.Sixty patients of primary pneumothorax were included in a prospective randomized study and divided into two groups. Group I (study) consisted of digital chest drainage system while in group II (control), conventional underwater-seal chest bottle system was used. Data was collected from January, 2012 to September, 2013 in Eulji University Hospital, Daejeon, Korea.There was no difference in age, sex, smoking history and postoperative pain between two groups. But the average length of drainage was 2.2 days in group I and 3.1 days in group II (P0.006). And more, about 90% of the patients in group I was satisfied with using new device for convenience.Digital system was beneficial on reducing the length of tube drainage by real time monitoring. It also had advantage in portability, loudness and gave more satisfaction than conventional system. Moreover, internet based digital drainage system will be a good method in thoracic telemedicine area in the near future.

The demographics and prognosis of non-small cell lung cancer patients have changed during the last few decades. We conducted this study to assess the change in demographics and prognosis in resected non-small cell lung cancer patients during a 20-yr single-institution study in Korea. We retrospectively reviewed the medical records of 2,076 non-small cell lung cancer patients who underwent pulmonary resection between 1990 and 2009. Their clinical characteristics and survival were analyzed over a five-year period. With time, the proportions of female, adenocarcinoma, stage IA, and lobectomy patients increased, whereas the proportions of male, squamous cell carcinoma, stage IIIA, and pneumonectomy patients decreased. These demographic changes caused improved prognosis. The five-year survival rate of all patients was 53.9%. The five-year survival rate increased from 31.9% in 1990-1994, to 43.6% in 1995-1999, 51.3% in 2000-2004, and 69.7% in 2005-2009 (P < 0.001). In conclusion, among patients with resected non-small cell lung cancer, the proportions of female, adenocarcinoma, stage IA, and lobectomy patients have increased, and the five-year survival rate has gradually improved during the last 20 yr in Korea.

Purpose Radiographic carpal chondromalacia (RCC) was defined as the presence of cortical sclerosis or subchondral changes, such as a lucent defect or cystic changes in a carpal on plain radiographs. The purpose of this study was to investigate the factors associated with the occurrence of RCC in idiopathic ulnar impaction syndrome and to determine the efficacy of ulnar shortening osteotomy on patient outcome and RCC. Methods Thirty-nine patients (42 wrists) with idiopathic ulnar impaction syndrome were treated with either ulnar shortening osteotomy or arthroscopic wafer resection. Patients were divided into 2 groups according to the presence (RCC group; 17 patients, 19 wrists) or absence (non-RCC group: 22 patients, 23 wrists) of RCC on preoperative radiographs. To determine the factors associated with RCC, a comparative analysis of these 2 groups was performed with respect to sex, age, duration of symptoms, positive ulnar variance, pain scores, and Chun and Palmer grading system. The RCC area was measured on serial radiographs taken during follow-up. Progressive changes of RCC area and clinical outcomes were evaluated. Results Patients in the RCC group were older, exhibited greater positive ulnar variance, and demonstrated a significantly higher mean pain score before surgery. The RCC was found to reverse over the year following ulnar shortening osteotomy and did not recur up to 2 years after surgery. In 3 wrists, RCC had completely disappeared at the last follow-up. All patients showed improved clinical outcomes. Conclusions The RCC changes correlated with older age, a positive ulnar variance, and preoperative pain severity. The RCC progressively reversed after ulnar shortening osteotomy, and this reversal of radiographic changes correlated with clinical improvements. Type of study/level of evidence Therapeutic IV.

Background: Pneumonectomy remains the ultimate curative treatment modality for destroyed lung caused by tuberculosis despite multiple risks involved in the procedure. We retrospectively evaluated patients who underwent pneumonectomy for treatment of sequelae of pulmonary tuberculosis to determine the risk factors of early and long-term outcomes. Materials and Methods: Between January 1980 and December 2008, pneumonectomy or pleuropneumonectomy was performed in 73 consecutive patients with destroyed lung caused by tuberculosis. There were 48 patients with empyema (12 with bronchopleural fistula [BPF]), 11 with aspergilloma and 7 with multidrug resistant tuberculosis. Results: There were 5 operative mortalities (6.8%). One patient had intraoperative uncontrolled arrhythmia, one had a postoperative cardiac arrest, and three had postoperative respiratory failure. A total of 29 patients (39.7%) suffered from postoperative complications. Twelve patients (16.7%) were found to have postpneumonectomy empyema (PPE), 4 patients had wound infections (5.6%), and 7 patients required re-exploration due to postoperative bleeding (9.7%). The prevalence of PPE increased in patients with preoperative empyema (p=0.019). There were five patients with postoperative BPF, four of which occurred in right-side operation. The only risk factor for BPF was the right-side operation (p=0.023). The 5- and 10-year survival rates were 88.9% and 76.2%, respectively. The risk factors for late deaths were old age (≥50 years, p=0.02) and low predicted postoperative forced expiratory volume in one second (FEV1) (＜1.2 L, p=0.02). Conclusion: Although PPE increases in patients with preoperative empyema and postoperative BPF increases in right-side operation, the mortality rates and long-term survival rates were found to be satisfactory. However, the follow-up care for patients with low predicted postoperative FEV1 should continue for prevention and early detection of pulmonary complication related to impaired pulmonary function.

Background The purpose of this study was to clarify the relationship between the tumor infiltrating lymphocytes and clinical outcome in patients with thymic carcinoma. Methods Tissue specimens from 32 patients who underwent surgical resection for thymic carcinoma were immunohistochemically analyzed for CD4, CD8 and CD20 expression. Results Tumor-infiltrating lymphocytes were generally more abundant in the stroma. The patients with low CD4+ lymphocytes ( p = 0.037) and low CD20+ lymphocytes ( p = 0.045) within tumor stroma showed poor survival. Furthermore, concurrent low levels of CD4+ and CD20+ ( p = 0.014), CD8+ and CD20+ ( p = 0.025), and, CD4+, CD8+, and CD20+ ( p = 0.025) in tumor stroma were significantly associated with poor prognosis when compared to the others group. Conclusion Our results indicate that infiltrating CD4+, CD8+, and CD20+ lymphocytes in cancer stroma may cooperate to suppress cancer progression and their presence together appear to be prognostic factor in thymic carcinoma.

Background: Following major lung resection, patients have routinely been monitored in the intensive care unit (ICU). Recently, however, patients are increasingly being placed in a general thoracic ward (GTW). We investigated the safety and efficacy of the GTW care after lobectomy for lung cancer. Materials and Methods: 316 patients who had undergone lobectomy for lung cancer were reviewed. These patients were divided into two groups: 275 patients were cared for in the ICU while 41 patients were care for in the GTW immediately post-operation. After propensity score matching, postoperative complications and hospital costs were analyzed. Risk factors for early complications were analyzed with the whole cohort. Results: Early complications (until the end of the first postoperative day) occurred in 11 (3.5%) patients. Late complications occurred in 42 patients (13.3%). After propensity score matching, the incidence of early complications, late complications, and mortality were not different between the two groups. The mean expense was higher in the ICU group. Risk factors for early complications were cardiac comorbidities and low expected forced expiratory volume in one second. The location of postoperative care had no influence on outcome. Conclusion: Immediate postoperative care after lobectomy for lung cancer in a GTW was safe and cost-effective without compromising outcomes in low-risk patients.

Empyema after lung transplantation causes dysfunction of the allograft, and it has the potential to cause mortality and morbidity, but the technical difficulty of surgically treating this empyema makes this type of treatment unfavorable. We report here on two cases of decortication for empyema after lung transplantation.

Background: Sternal fractures are relatively rare, and caused mainly by blunt anterior chest wall trauma. In most cases, sternal fractures are treated conservatively. However, if the patient exhibits problematic symptoms such as intractable chest wall pain or bony crepitus due to sternal instability, surgical correction is indicated. But no consensus exists regarding the most appropriate surgical method. We analyzed the results of surgical fixation in cases of sternal fracture in order to identify which surgical method led to the best outcomes. Methods: We retrospectively reviewed the medical records of patients with sternal fractures from December 2008 to December 2011, and found 19 patients who underwent open reduction and internal fixation of the sternum with a longitudinal plate (L-group) or a T-shaped plate (T-group). We investigated patients’ characteristics, clinical details regarding each case of chest trauma, the presence of other associated injuries, the type of open reduction and fixation, whether a combined operation was performed, and postoperative complications. Results: Of the 19 patients, 10 patients (52.6%) were male, and their average age was 56.8 years (range, 32 to 82 years). Seven patients (36.8%) had isolated sternal fractures, while 12 (63.2%) had other associated injuries. Seven patients (36.8%) were in the L-group and 12 patients (63.2%) were in the T-group. Three patients in the L-group (42.9%) showed a loosening of the fixation. In all patients in the T-group, the fracture exhibited stable alignment. Conclusion: Open reduction and internal fixation with a T-shaped plate in sternal fractures is a safer and more efficient treatment method than treatment with a longitudinal plate, especially in patients with a severely displaced sternum or anterior flail chest, than a longitudinal plate.

A 31-year-old female was referred from other hospital due to migrating chest pain, mild cough, and blood-tinged sputum for three days before admission. Laboratory tests were unremarkable. Chest computed tomography revealed an elliptical necrotic mass at the left anterior mediastinum, measuring 7×3×4 cm. With the impression of mediastinal abscess or loculated empyema, thoracoscopic resection was performed. There was severe pleural adhesion around the mass. The mass could be resected by the wedge resection of the adhesed upper lobe tissue of left lung around the mass. Final pathologic diagnosis was ectopic pancreas.

Purpose: To evaluate the efficacy of taurolidine instillation on postoperative air leak by clini-cal study and to investigate the mechanism of action by animal experiments.Methods: Outcomes of taurolidine instillation in patients with postoperative air leak were retrospectively reviewed. 100 ml of 1% taurolidine solution was instilled through a chest tube in patients with postoperative air leak lasting 4days or more. Success was defined as cessation of air leak within 24 hours with full expansion of lung on chest radiograph and subsequent removal of chest tube within another 24 hours. The effect of taurolidine instillation was esti -mated by development of adhesion and thickening of the visceral pleura in rabbits. The study group was compared with a control group and a talc poudrage group.Results: Out of 75 patients, the success rate was 66.7%. Out of 96 total attempts, taurolidine instillation was successful in 55%. In animal experiments, pleural adhesion was minimal in the taurolidine and control groups, whereas the talc group showed more adhesions. The tau -rolidine group showed a moderate visceral pleural thickening. The talc group showed severe visceral pleural thickening, whereas the control group showed mild thickening. Conclusion: Taurolidine is an effective alternative agent for the management of air leak. A chemical sclerosing effect is suggested as the mechanism of air leak cessationKeywords

Introduction: Clinical outcomes and prognosis of recurrent thymoma are not well known because of its rarity and indolent clinical course. This study was designed to determine the clinical outcomes and prognosis of recurrent thymoma. Methods: Between 1986 and 2009, 41 of 305 patients who underwent resection for thymoma had recurrence. We reviewed those patients retrospectively. Results: Of 15 patients who underwent re-resection for recurrent thymoma, 13 patients (87%) achieved complete re-resection. Of 26 patients who did not undergo re-resection, 11 patients received chemotherapy, five received chemoradiotherapy, one received another treatment, and nine patients did not receive any treatment. World Health Organization histological types AB or B1 and complete re-resection were positive prognostic factors. The complete re-resection group had better survival after recurrence than the non/incomplete re-resection group (5-year survival rate: 90.9% versus 44.7%, p = 0.014). The complete re-resection group had comparable survival after initial resection of thymoma to the patients without recurrence (5-year, 10-year survival: 91.7%, 91.7% versus 90.7%, 86.5%, p = 0.618) and better survival compared with the non/incomplete re-resection group (5-year, 10-year survival: 91.7%, 91.7% versus 81.6%, 56.7%, p = 0.018). Conclusions: World Health Organization histologic types AB or B1 and complete re-resection are favorable prognostic factors of recurrent thymoma. In particular, complete re-resection of recurrent thymoma contributes to better survival than other management. Therefore, we suggest that long-term surveillance extended at least 20 years may be essential for early detection of recurrence to increase the chance of complete re-resection of recurrent thymoma.

Background This study was designed to analyze the predictive factors for survival in second primary lung cancer patients following operation. Methods A total of 1852 patients who underwent resection for primary lung cancer between January 1990 and December 2008 were reviewed, retrospectively. Results Nineteen patients were treated for synchronous second primary lung cancer and 23 patients were treated for metachronous cancer. The overall 5-year survival rate for patients with synchronous second primary lung cancer was comparable to that of patients with single-lung cancer (51.4 vs. 48.7%, p = 0.755). The overall 5-year survival rate after the first tumor resection in patients with metachronous second primary lung cancer was significantly better than that of patients with single-lung cancer (85.4 vs. 48.7%, p = 0.003), but was not significantly different after the second tumor resection (77.0 vs. 48.7%, p = 0.057). Conclusion Surgically resected second primary lung cancer had a survival comparable with single-lung cancer. Histologic concordance between the first and second tumors, and the pathological stage were important prognostic factors in second primary lung cancer.

Background We retrospectively reviewed the clinical features and surgical outcomes of patients with a surgically resected NSCLC invading chest wall in order to identify prognostic factors that impact long term survival. Methods Between January 1990 and December 2009, 107 patients who underwent surgical resection for chest wall invading NSCLC were reviewed. Tumors invading only the parietal pleura were defined as superficial invasions, and those involving the soft tissue or ribs were defined as deep invasions. Results There were 91 men and 16 women; median age was 64 years (range 30 to 80 years). Overall 5 year survival rate was 26.3%. The univariate prognostic factors for survival included gender, extent of resection (pneumonectomy vs lobectomy), tumor size(> 5 cm vs ≤ 5 cm), nodal status (N0 or N1 vs N2), completeness of resection (complete vs incomplete) and completeness of adjuvant chemotherapy. At multivariate analysis, five independent prognostic factors were shown; depth of invasion (superficial vs deep), tumor size, nodal status, completeness of resection, and completeness of adjuvant chemotherapy. In patients with completely resected T3N0 NSCLC, completion of chemotherapy is the only prognostic factor for long term survival. Conclusions Completeness of resection, nodal status, depth of invasion, tumor size, and adjuvant chemotherapy were prognostic factors for long-term survival in NSCLC patients with chest wall invasion. Because of poor prognosis in cases with chest wall invasion that have N2 positive LN, that is difficult to achieve complete resection and that need pneumonectomy, definite chemoradiotherapy or neoadjuvant chemoradiotherapy should be considered first in these cases.

Purpose To investigate the incidence of bilateral discoid lateral meniscus (DLM) and to evaluate the arthroscopic features of lateral meniscus in asymptomatic contralateral knees in an Asian population who presented with symptomatic DLMs. Methods This study prospectively enrolled 52 consecutive patients who underwent arthroscopic procedures for symptomatic DLMs (31 complete and 21 incomplete) and who consented to the examination of the contralateral knee at the time of arthroscopy. Types of DLMs and of meniscus tears were assessed by use of arthroscopic findings. Preoperative and postoperative functional outcomes were evaluated with Lysholm and Tegner activity scores. Results Arthroscopic examinations showed 21 complete DLMs, 19 incomplete DLMs, 11 normal lateral menisci, and 1 ring-shaped lateral meniscus in contralateral knees. The incidence of bilateral DLM in our study population was 79% (41 of 52 contralateral knees). Furthermore, 65% of patients (34 pairs of knees) had the same DLM types. In addition, 3 pairs of knees with complete DLMs had menisci of different thicknesses. DLM tears were observed in 2 contralateral knees (1 radial and 1 longitudinal) and were treated by partial central meniscectomy. Conclusions This study provides evidence of the high prevalence of bilateral DLM in an Asian population. Level of Evidence Level I, testing of previously developed diagnostic criteria in a series of consecutive patients.

Background This study was designed to assess the treatment of patients in whom a second primary lung cancer developed after the resection of primary lung cancer. Methods Between January 1990 and December 2008, 1852 patients underwent complete resection for primary lung cancer in our institution. Of these individuals, patients who had been identified as having a second primary lung cancer by December 2009 were selected for this study using the criteria proposed by Martini and Melamed. Results Of 1852 patients, a second primary lung cancer developed in 40 (2.2%) during the follow-up period. The overall 5-year and 10-year survival rates after the resection of the first tumor were 78.3% and 39.9%, respectively. The overall 5-year survival rate from the time of detection of the second primary lung cancer was 47.8%, and the 5-year survival rate of the patients who underwent resection of the second tumor was 77.0%. The patients who underwent sublobar resection had comparable overall survival and disease-free survival compared with the patients who underwent anatomic resection. Additionally, the patients who underwent sublobar resection had a better operative outcome. Conclusions Surgical resection is feasible and effective in the management of second primary lung cancer, and sublobar resection may be adequate. Long-term surveillance of more than 5 years is essential for early detection to increase the chance of resection of a second primary lung cancer.

Background: Aortic valve replacement (AVR) improves left ventricular (LV) systolic function in patients with chronic aortic regurgitation (AR). The objective of this study is to determine predictors for normalization of impaired LV systolic function after valve replacement for chronic AR. Methods and Results: Between 1997 and 2007, 171 patients underwent AVR for severe chronic AR. Of these patients, 79 patients with LV systolic dysfunction or severe LV dilatation preoperatively, who were evaluated by echocardiography at predischarge and early follow up (mean, 6 months) were examined. The mean preoperative ejection fraction was 49%. The mean LV end-systolic and end-diastolic dimensions were 52.32±8.35mm and 69.59±7.80mm, respectively. In the early follow up, 62 of 79 patients exhibited restored normal LV function. LV end-systolic dimension and LV end-diastolic dimension were significantly decreased early after AVR (52.32±8.35mm vs 37.82±6.88mm, and 69.59±7.80mm vs 51.55±6.40mm, respectively). Operative mortality was 3.7%. Multivariate stepwise regression analysis revealed that preoperative indexed LV end-systolic and end-diastolic dimensions were independent predictors of restored LV systolic function. The sensitivity and specicity in predicting normalization of LV function were 88% and 92% for indexed LVESD

Background: Totally implantable access port (TIAP) provides reliable, long term vascular access with minimal risk of infection and allows patients normal physical activity. With wide use of ports, new complications have been encountered. We analyzed TIAP related complications and evaluated the outcomes of two different percutaneous routes of access to superior vena cava. Methods: All 172 patients who underwent port insertion with internal jugular approach (Group 1, n = 92) and subclavian approach (Group 2, n = 79) between August 2011 and May 2013 in a single center were analyzed, retrospectively. Medical records were analyzed to compare the outcomes and the occurrence of port related complications between two different percutaneous routes of access to superior vena cava. Results: Median follow-up for TIAP was 278 days (range, 1-1868). Twenty four complications were occurred (14.0%), including pneumothorax (n = 1, 0.6%), migration/malposition (n = 4, 2.3%), pinch-off syndrome (n = 4, 2.3%), malfunction (n = 2, 1.1%), infection (n = 8, 4.7%), and venous thrombosis (n = 5, 2.9%). The overall incidence was 8.7% and 20.3% in each group (p = 0.030). Mechanical complications except infectious and thrombotic complications were more often occurred in group 2 (p = 0.033). The mechanical complication free probability is significantly higher in group 1 (p = 0.040). Conclusions: We suggest that the jugular access should be chosen in patients who need long term catheterization because of high incidence of mechanical complication, such as pinch-off syndrome.

There is an increasing incidence of mortality among trauma patients; therefore, it is important to analyze the trauma epidemiology in order to prevent trauma death. The authors reviewed the trauma epidemiology retrospectively at a regional emergency center of Korea and evaluated the main factors that led to trauma-related deaths.A total of 17007 trauma patients were registered to the trauma registry of the regional emergency center at Wonju Severance Christian Hospital in Korea from January 2010 to December 2012.The mean age of patients was 35.2 years old. The most frequent trauma mechanism was blunt injury (90.8%), as well as slip-and-fall down injury, motor vehicle accidents, and others. Aside from 142 early trauma deaths, a total of 4673 patients were admitted for further treatment. The most common major trauma sites of admitted patients were on the extremities (38.4%), followed by craniocerebral, abdominopelvis, and thorax. With deaths of 126 patients during in-hospital treatment, the overall mortality (142 early and 126 late deaths) was 5.6% for admitted patients. Ages ≥55, injury severity score ≥16, major craniocerebral injury, cardiopulmonary resuscitation at arrival, probability of survival25% calculated from the trauma and injury severity score were independent predictors of trauma mortality in multivariate analysis.The epidemiology of the trauma patients studied was found to be mainly blunt trauma. This finding is similar to previous papers in terms of demographics and mechanism. Trauma patients who have risk factors of mortality require careful management in order to prevent trauma-related deaths.

There has recently been increasing interest in the development of radioprobes that specifically target proteins transcribed from expression of reporter genes of interest. The purpose of this study was to develop a radioprobe that targets one of the most widely used reporter genes, the bacterial lacZ gene. We synthesised and purified radioiodine-labelled phenylethyl-beta- d-thiogalactopyranoside (PETG), a competitive inhibitor specific against Escherichia coli beta-galactosidase. We showed that [(125)I]iodo-PETG specifically binds to beta-galactosidase as verified by column chromatography and polyacrylamide gel electrophoresis after incubation of radiotracer with the protein. We also showed through enzyme kinetic studies that iodo-PETG retains inhibitory action against beta-galactosidase activity. COS-7 cells infected with a recombinant adenovirus expressing the lacZ gene had viral titre-dependent enhancements in [(125)I]iodo-PETG uptake ( r(2)=0.897; P=0.001), which reached up to 642.5%+/-16.7% of control levels ( P0.00001). Moreover, the level of uptake was highly correlated to luminescent measurements of beta-galactosidase activity ( r(2)=0.878; P0.0001). These results confirm that radioiodine-labelled PETG specifically targets beta-galactosidase and that its uptake rates faithfully reflect levels of expression of the lacZ reporter gene. Further investigations were performed in nude mice bearing human neuroblastoma tumours transferred with the lacZ gene. Compared with control tumours, lacZ-expressing tumours were slightly better visualised on [(123)I]iodo-PETG images and had a modest increase in tumour to muscle count ratio (2.6+/-0.2 vs 1.9+/-0.1, P0.05). The present results provide proof-of-principle for the potential of radiolabelled inhibitors as promising radiotracers to monitor lacZ gene expression levels. Future modifications to improve cell permeability should enhance in vivo contrast levels and may allow the use of radiolabelled beta-galactosidase inhibitors for non-invasive monitoring of lacZ gene expression.

Angiostatin (AS) is a potent antiangiogenic agent which inhibits tumor growth through specific action on proliferating endothelial cells. Imaging of radiolabeled AS would enhance our knowledge on the pharmacokinetics of AS and might provide useful information relating to tumor neovasculature. We therefore investigated the potential of radiolabeled AS as a novel tumor imaging agent. Human angiostatin was radioiodine labeled using the lactoperoxidase method. Competition binding studies showed a dose-dependent inhibition of (125)I-AS binding to endothelial cells by excess unlabeled AS, and a displacement curve demonstrated that specific binding was dose dependent and saturable, with a K(d) value of 169 n M. Gel analysis showed that (125)I-AS remained stable in serum for up to 24 h without significant degradation. Intravenously injected (125)I-AS in rats was cleared from the blood in an exponential fashion. Biodistribution data from human colon cancer-bearing Balb/C nude mice showed high uptake in the kidneys, stomach, liver, and lungs. Tumor uptake was 3.2+/-0.7, 2.6+/-0.2, and 1.7+/-0.2%ID/g at 2, 4, and 9 h after injection, respectively. Tumor to muscle count ratio increased from 3.1+/-0.5 at 2 h to 4.4+/-0.5 at 9 h. Serial scintigraphy from 1 to 5 h after (123)I-AS injection demonstrated high uptake in the kidneys and bladder, consistent with renal excretion. There was clear demarcation of tumor by 1 h, with gradual increase in contrast over time (4-h tumor to contralateral thigh ratio =4.7+/-1.1). Thus, radioiodine-labeled angiostatin binds specifically to endothelial cells and has potential as a novel tumor imaging agent.