Search

Objective To evaluate the effect of systemically administered urokinase (UK) after percutaneous transluminal angioplasty with or without stent (PTA ± stent) on the reduction in the rate and level of amputation in patients with critical limb ischemia (CLI) with tissue loss. Methods This was an observational, nonrandomized, retrospective study of 183 Taiwanese patients with Rutherford stage 5 or 6, and Fontaine stage 4 lower extremity CLI. Patients received either PTA ± stent or PTA ± stent + UK infusion (250,000 IU, daily for 5 days). PTA of the iliac, femoral, anterior tibial artery, posterior tibial artery, and peroneal arteries was included. Amputation was classified as minor, with direct wound healing, and minor amputation or surgical debridement of toes and major, with below- (BKA) and above-knee amputation (AKA). Results In groups of patients with comparable baseline characteristics, 85 and 90 patients received PTA ± stent and PTA ± stent + UK, respectively. There were 24 major limb amputations performed. A significant majority (20/24 (83.3%) were performed in patients who did not receive adjuvant urokinase, compared with 4/24 (16.7%) of patients who did receive urokinase ( p = 0.000287). There was a significant increase in the limb salvage rate for infrapopliteal lesions in patients treated with PTA + UK (12/72 with UK; 60/72 without UK; p ≤ .0001). Intracranial hemorrhage ( n = 1) and bleeding at the inguinal puncture site ( n = 2) were reported in the PTA ± stent + UK group. Eight deaths (one in the PTA ± stent + UK group; seven in the PTA ± stent) occurred during the study. Conclusion Systemic administration of UK with the PTA ± stent procedure may reduce the requirement for major amputation in patients with CLI with tissue loss (Rutherford 5 or 6). The difference is more pronounced in patients undergoing infrapopliteal interventions. However, these findings need to be confirmed in a randomized prospective study.

Background/Purpose Thymectomy may benefit patients with generalized myasthenia gravis (MG) or myasthenia with thymomas. Currently, video-assisted (VA) thoracic surgery is popular and plays an important role in thymectomy. We compared the clinical outcomes of VA thymectomy with conventional transsternal (TS) approach to investigate the effectiveness of VA technology in the current era. Methods A retrospective review of our thymectomy results for patients with MG from 1998 to 2011 was conducted. A total of 83 consecutive patients were enrolled. According to the surgeons’ and patients’ preference, 39 patients received conventional TS thymectomy and 44 were operated on in a VA fashion. The results were categorized and analyzed according to the Myasthenia Gravis Foundation of America (MGFA) postintervention statuses with some modification. Results No obvious difference between conventional TS thymectomy and VA thymectomy was noted regarding the remission statuses and the clinical outcomes by the modified MGFA score. However, the patients who received VA thymectomy showed shorter intensive care unit (ICU) stays (4.2 ± 3.3 days vs. 2.3 ± 1.5 days, p = 0.001). Conclusion Compared with the conventional TS thymectomy, the VA approach is similarly effective with shorter ICU stays.

Introduction: The aim of this study is to evaluate whether the administration of renin-angiotensin system (RAS) inhibitors, angiotensin-I converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), is associated with treatment outcome in patients with esophageal squamous cell carcinoma. Materials and methods: A total of 141 esophageal squamous cell carcinoma patients receiving esophagectomy were identified, and were divided into two groups: an ACEI/ARB group ( n =20), and a non-ACEI/ARB group ( n =121). The effect of ACEIs or ARBs on cell proliferation and vascular endothelial growth factor (VEGF) secretion of esophageal squamous cell carcinoma cell lines, CE81T/VGH and TE2, were investigated by 3-(4.5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and Enzyme-linked immunosorbent assay (ELISA), respectively. Results: Use of ACEI/ARB ( p =0.032), pathologic T stage ( p

Management of postpneumonectomy empyema has always been a challenging task. Local flaps or free muscle flaps are options for recalcitrant cases when traditional therapeutic attempts fail. This report presents 2 patients with chronic postpneumonectomy empyema who were treated with an anterolateral thigh combined flap consisting of vastus lateralis and rectus femoris muscles. This method showed promising results for reconstruction of large empyema defect.

Seven unusual cases of esophageal bronchogenic cyst (EBC) are presented. Different from mediastinal or pulmonary bronchogenic cysts, EBCs predominately affect young women (six out of seven cases; mean age, 29.9 years), and clinically, such cases were characterized by dysphagia and chest pain, especially during exercise. On radiographs and computed tomographs, EBCs typically appeared as 3- to 4-cm midthoracic cystic masses close abutting to the midthoracic esophagus. Rarely, exophytic lower thoracic EBC may mimic lung nodule. Total cyst excision usually offers satisfactory outcome with no recurrence in long-term follow-up.

The purpose of our study was to assess the clinical feasibility of MDCT angiography for evaluating hemodialysis arteriovenous fistulas (AVFs).MDCT angiography of the complete vascular trees of 36 failing AVFs or AVF-related complications (20 native and 16 polytetrafluoroethylene graft AVFs) was reviewed. The numbers and degrees of stenoses at the anastomoses, graft loops, and draining and central veins and the presence of aneurysms or thrombosis were recorded. Wilcoxon's signed rank test was used to compare the findings of MDCT angiography with those of digital subtraction angiography (DSA) (n = 10), surgery (n = 22), or both (n = 4) performed within 2-6 days. Kappa statistics were used to correlate the clinical feasibility of MDCT angiography assessed by two reviewers.Among the 14 AVFs examined with both MDCT angiography and DSA, no significant difference was seen in the detection and grading (p = 0.317 to0.999) of stenoses at various segments of the entire vascular tree. Among the 36 AVFs examined, MDCT angiography also showed no significant difference from DSA or surgery in revealing vascular stenoses, aneurysms, and thromboses from the supplying artery to central veins (p = 0.317 to0.999). Overall, the sensitivity, specificity, positive and negative predictive values, and accuracy of MDCT angiography in lesion detection were 98.7%, 97.5%, 98.8%, 97.2%, and 98.3%, respectively. High image quality with superb interobserver correlation (kappa = 0.809 to0.999) validated the clinical feasibility of MDCT angiography for assessing AVFs.MDCT angiography is clinically feasible for evaluating the complete vascular tree of failing AVFs and in showing uncommon complications, including brachial aneurysms and central vein lesions.

On computed tomography (CT), neurilemomas have generically been described as well-defined, round masses with heterogeneous contrast enhancement. The CT scans of 38 surgically proven thoracic neurilemomas in 36 patients were reviewed to characterize further the CT features of this tumor, with an emphasis on different enhancement patterns. Unenhanced CT was available in 32 patients; 10 tumors appeared isodense, and 22 tumors appeared slightly hypodense compared with chest wall muscle. Except for an intraosseous neurilemoma of the T8 vertebral body, which mimicked bone metastasis, the tumors could be categorized into five different patterns on CT after contrast enhancement. Twenty tumors (54.1%) revealed diffuse, but amorphous and inhomogeneous enhancement. Seventeen (45.9%) tumors appeared as masses with multiple hypodense or cystic areas. Of these 17, the pattern was somewhat radial enhancement (n = 6, 16.2%), peripheral enhancement with a large central hypodense area (n = 5, 13.5%), homogeneous hypodensity (n = 5, 13.5%), and central enhancement with peripheral hypodensity (n = 1, 2.7%). Appreciation of various CT manifestations is important in the diagnosis of this tumor.

We report a case of a 45-year-old man with a recurrent, large, invasive dermatofibrosarcoma protuberans over the left lower chest and abdomen. Wide surgical excision of the tumor created a major thoracoabdominal wall defect. Wound coverage was achieved by using a flow-through forearm flap and an inferiorly based latissimus dorsi-groin flap. Follow-up at 1 year revealed no local recurrence or herniation.

Study objective With the improvements in video-assisted thoracoscopic surgery, more older patients and patients with respiratory impairments are undergoing bulla ablation using new and costly technology. We evaluated the cost-effective technique of thoracoscopic endoloop ligation of bullae in patients with bullous emphysema. Patients: From March 1992 through January 1996, 79 advanced age (mean age, 64 years) and oxygen dependency patients underwent thoracoscopic procedure using endoloop ligation for treatment of bullous emphysema. Clinical data were collected from chart review. Only patients with radiographically confirmed diagnosis of bullous emphysema were included in this evaluation. Thoracoscopic endoloop ligation of bulla was carried out under general anesthesia with double-lumen endotracheal tube and single-lung ventilation. Results Sixty-five patients (82%) exhibited subjective improvement in their symptom status at 3-month follow-up (from grade 2 or 3 to grade 1 or 2) according to the Modified Medical Research Council dyspnea scale. The mean duration of chest drainage was 6 days (range, 4 to 16 days). Average hospital stay was 9.5 days (range, 5 to 26 days). There was no postoperative death. A comparison of preoperative and postoperative functional evaluation was available in only 16 patients who showed an increase in FEV 1 (from 0.85 to 1.02 L) and a decline in residual volume after operation. Complications include persistent airleak over 10 days in seven patients (8.9%), wound infection in three patients, and localized empyema in two patients. There was no recurrence after a mean follow-up of 21 months. Conclusion These encouraging results have shown that thoracoscopic endoloop ligation of bulla has proved to be a safe, reliable, and cost-effective technique for bullous emphysema. With careful preoperative evaluation and meticulous postoperative care, many patients could be rehabilitated by endoloop litigation of the bullae.

A total of 82 consecutive patients with recurrent or persistent spontaneous pneumothorax were considered for thoracoscopic blebectomy or bullectomy and pleurodesis. The median age was 47 years, and 70% were men. All the patients were successfully treated using a video-assisted thoracoscopic technique. There were no deaths attributable to the procedure. Complications occurred in 6 patients (7.3%). Three patients (4%) with diffuse bullous lung disease had prolonged intubation (9, 11, and 12 days, respectively). Persistent air leaks lasting from 10 to 14 days occurred in 2 patients (3%). One patient had an endoloop slip from the lung parenchyma after a forceful sneeze 2 days after the operation. Air leak subsided after the second operation using a conventional suturing technique. Blebs or bullae were present in 69 patients (83%). These were ablated by endoscopic stapling (37 patients) and through thoracoscopic ligation using an endoloop technique (32 patients). In this group of patients, the median postoperative hospital stay was 5 days. Thirteen patients with air leaks and diffuse bullous lung disease received only talc insufflation thoracoscopically. All of them showed good lung expansion after the operation. There are no recurrences, with a mean follow-up of 22 months. These results suggest that thoracoscopic ablation of blebs or bullae and pleurodesis may be applicable to patients with spontaneous pneumothorax who require surgical intervention.

Hypothermic circulatory arrest is commonly used to facilitate repair of complex congenital heart defects and aortic lesions and for complex neurosurgical procedures. However, extended periods of circulatory arrest may impair cerebral metabolism and cause ischemic injury. Retrograde cerebral perfusion has been applied recently in aortic surgery to protect the brain. From January 1991 to December 1993, 29 patients underwent emergency operations to repair acute type A aortic dissection with the aid of hypothermic circulatory arrest. Six patients received hypothermic circulatory arrest without retrograde cerebral perfusion with a rectal temperature of 16.4° ± 0.9° C (mean ± standard error of the mean, group 1). Retrograde cerebral perfusion during hypothermic circulatory arrest was performed in 15 patients with a rectal temperature of 15.9° ± 0.5° C (group 2) and in eight patients with a rectal temperature of 21.7° ± 0.8° C (group 3). The hypothermic circulatory arrest times were 25 ± 4, 42 ± 4, and 63 ± 6 minutes, respectively ( p p

Thoracoscopy has assumed a major role in the management of a variety of surgical diseases of the chest. This technique, which was primarily devised for diagnostic purposes, has subsequently come to be used for therapeutic applications in most centers today. In this report we review 300 cases of therapeutic thoracic procedures in which a video-assisted technique was used. We describe mainly our own experience and the basic approach strategies we found helpful in the video-assisted procedures. No complications or deaths were attributable to these procedures. Our conclusions were as follows: (1) Video-assisted thoracic surgery can be as effective therapeutically as many formal thoracotomy. (2) Excellent exposure can be obtained by the use of double-lumen endotracheal tubes. (3) Video-assisted thoracic surgery is an excellent alternative treatment for pneumothorax, blebs, and bullous disease. (4) Video-assisted thoracic surgery allows safe, complete, visually guided wedge resection of lung lesions, lobectomy, pericardiectomy, removal of mediastinal tumor, esophagectomy, and reconstruction of the thoracic esophagus. (5) Video-assisted thoracic surgery also allows management of a broad scope of other general thoracic diseases such as empyema, pleural effusion, and chest trauma (hemothorax), as well as cancer staging. (6) Video-assisted thoracic surgery will not compromise the primary diagnostic and therapeutic goals set forth for the patient. (7) Because conventional instruments and extended manipulation incisions can be used, video-assisted thoracic surgery offers the promise of expediency, safety, minimal discomfort, less postoperative pain, quick functional recuperation, excellent cosmetic healing, shortened stays in the hospital, and therefore savings in cost. Accordingly, we are now using video-assisted thoracic surgery to treat the majority of patients with surgical diseases of the chest.

Coronary artery endothelium exhibits functional impairment after ischemia and reperfusion. Canine left anterior descending coronary arteries were exposed to ischemia (60 minutes) followed by reperfusion (60 minutes) through a left internal mammary artery graft. In organ chamber experiments, control (left circumflex coronary artery) and reperfused (left anterior descending coronary artery) arterial segments were contracted with prostaglandin F2 alpha and exposed to hypoxia (oxygen tension = 35 +/- 5 mm Hg). Reperfused coronary rings with endothelium exhibited contractions to hypoxia that were significantly greater than contractions in control rings with endothelium (+78% +/- 8% and +14% +/- 5%, respectively; p < 0.05). This phenomenon could be blocked by NG-monomethyl-L-arginine. Electron microscopic studies showed platelet adhesion and aggregation, denudation of the endothelium and disruption of the intercellular junctions, edematous subendothelial matrix, and vesiculation of the smooth muscle cells in reperfused LAD. Swelling, vacuole formation, and loss of neurofilament occurred in the nerve fibers accompanying the vessels. These phenomena were not observed in control vessels. This study demonstrates that early after coronary artery bypass grafting, hypoxia can induce coronary vasospasm mediated by an L-arginine-dependent metabolic pathway in the endothelium. The ultrastructural changes in the coronary endothelium include platelet adhesion, aggregation, and platelet-induced contraction of coronary smooth muscle. The endothelium-dependent hypoxic coronary vasospasm and ultrastructural changes in the coronary endothelium may play an important role in the pathogenesis of myocardial ischemia and infarction after coronary artery bypass grafting.

Prosthetic rings are customarily used for mitral annuloplasty to plicate and reinforce the annulus and keep the annulus from further dilating. From July 1984 to Match 1992, mitial annular plication using polytetrafluoroethylene (PTFE) graft material was performed on 73 patients (age range, 15 to 69 years; mean, 35.7 years) with mitral regurgitation. The cause of the mitral regurgitation was rheumatic in 50.7% and degenerative in 36.9% of the patients. After other repair procedures on the mitral valve apparatus had been performed, a PTFE graft (3 mm) was tailored to the length of the free edge of the anterior leaflet and then inserted at the posterior part of the mitral annulus between the commissures. The operative mortality was 2.7%. Follow-up ranged from 0.7 to 8.5 years (mean, 5.6 years). Postoperative echocardiography confirmed that 94.2% of the survivors had either no or only mild mitral regurgitation with a large mitral valve area (2.7 ± 0.3 cm 2 ) and almost no pressure gradiant across the mitral valve or left ventricular outflow tract. Two patients successfully underwent redo PTFE mitral annuloplasty. Two patients died, one 15 and the other 20 months later, due to myocardial failure, with no mitral regurgitation. The event-free survival rate was 90% ± 4% at 8 yean. We conclude that PTFE mitral annuloplasty is an effective procedure that yields good long-term results.

University of Wisconsin (UW) solution has been demonstrated to enhance and extend the preservation of the hepatic, pancreatic, renal, and cardiac allografts. Prostaglandin E1 (PGE1), which has been used to produce pulmonary vasodilatation, has improved preservation in lung transplantation. Experiments were designed to evaluate their potential role in 24-h preservation of the allografts in lung transplantation. Thirty-six dogs underwent left lung transplantation. The donor lungs (n = 6 in each group) were flushed with UW solution (group 1 and 2) or modified Euro-Collins (EC) solution (group 3) after PGE1 infusion (500 micrograms). In group 1, donor lungs were transplanted immediately. Lung allografts of group 2 and 3 were cold stored (4 degrees C) in the same preservation solution for 24 h in the inflated state and then transplanted. The right pulmonary artery and right main bronchus were ligated 1 h after completion of the transplantation, forcing the recipient dogs to survive with the transplanted left lung. The recipients were ventilated with an inspired oxygen fraction of 0.4 and end-expiratory pressure 10 cm H2O. Two dogs died prematurely in group 3, whereas all dogs in group 1 and 2 survived the experimental period. The arterial oxygen tension and saturation and dynamic lung compliance were significantly higher in dogs of group 1 and 2. Transplanted lungs of group 1 and 2 had significantly lower pulmonary vascular resistance, alveolar-arterial oxygen difference, and wet/dry lung weight ratio. Histologically, pulmonary edema, congestion, sloughing of bronchial mucosa, and peribronchial and peripulmonary arterial hemorrhage were shown in lungs of group 3, but not in those of group 1 and 2. Airway mucosa and pulmonary vascular structure were well preserved in lungs of group 1 and 2. There was no significant difference between group 1 and 2 in lung functions, hemodynamics, or morphologic features. We concluded that PGE1 and UW solution could effectively extend lung preservation up to 24 h in this in vivo canine lung allotransplantation model.

Mesenchymal chondrosarcoma has been well documented in the somatic soft tissue and bone. It is a rare subtype of chondrosarcoma characterized by the presence of islands of chondroid or by less osteoid tissue enmeshed within dense sheets of primitive small blue mesenchymal cells with hemangiopericytoma-like vessels, or by both. The vast majority of previously published pulmonary mesenchymal chondrosarcoma was metastatic. To the best of our knowledge, only one case of primary pulmonary mesenchymal chondrosarcoma has been described in the literature. Herein, we report the second case of primary mesenchymal chondrosarcoma of the lung and emphasize that biopsy may yield only nonspecific small blue cells, whereas a detailed evaluation of the resected specimen allows definite diagnosis of this rare lung tumor.

Actinomycotic infection is uncommon and primary actinomycosis of the lung and chest wall has been less frequently reported. This disease may present as chronic debilitating illness with radiographic manifestation simulating lung tumor, pulmonary infiltrating lesion, or chronic suppuration. From 1984 to 1990, we experienced 17 cases of thoracic actinomycosis. There were nine patients who presented with a clinical picture of a suppurative lesions and the remaining eight were suspected of having primary lung tumor initially. In no case was an accurate diagnosis made at the time of hospital admission. Final diagnosis was based on aspiration (n = 3), anaerobic sputum culture (n = 1), bronchoscopic biopsy specimens (n = 4), and histologic examination of the resected tissue in the remaining 9 patients who received surgical excision. Among the 17 patients, 8 were treated medically and the other 9 received surgical intervention followed by antibiotic treatment. Regarding the surgically treated patients, suspected malignancy is the most common indication for operation (seven of nine). However, both medically and surgically treated patients achieved good clinical results, and the postoperative courses were uneventful. We would like to remind physicians of this unusual entity and review our own experience with particular emphasis on the clinical diagnosis and management of this unique disease.

We evaluate if C-reactive protein (CRP) is an objective biomarker of esophageal cancer in patients undergoing radiotherapy.Between November 2002 and July 2007, 123 patients undergoing radiotherapy for newly diagnosed esophageal cancer were enrolled. Serum CRP concentration was measured before the initiation of treatment. The relationship between serum CRP levels and other relevant variables such as body mass index, white blood cell count, platelet count, bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), cholesterol, hemoglobin, and albumin levels was also analyzed.Eighty-one patients of the 123 patients enrolled (65.9%) had elevated CRP levels (5mg/L). The 2-year survival for patients with CRP 5mg/L was 7.8% compared to 78.4% for patients with CRP5mg/L. Hypoalbuminemia (albumin3.5g/dL) was also related to shorter survival using univariate analysis. Multivariate analysis demonstrated that only higher serum CRP concentration and hypoalbuminemia were independent prognostic indicators for survival of patients with esophageal cancer.Pretreatment serum levels of CRP and albumin are objective, easily measurable biomarkers which can be used in combination with conventional staging to accurately predict survival in patients with esophageal cancer treated with radiotherapy.

To prospectively assess muscle metabolism in myasthenia gravis (MG) patients before and after thymectomy by using phosphorus 31 (31P) magnetic resonance (MR) spectroscopy.With institutional review board approval and informed consent, resting and dynamic (31)P MR spectroscopy were performed in 14 healthy volunteers (five men, nine women; mean age, 33 years; range, 23-48 years) and 16 MG patients (six men, 10 women; mean age, 37 years; range 18-50 years) before and after thymectomy. Patients were stratified into groups according to the modified Osserman classification: mild-MG group (classes I-IIA) and moderate-to-severe-MG group (classes IIB-IV). Variables compared among the three groups (Kruskal-Wallis test) included the inorganic phosphate (P(i))-adenosine triphosphate (ATP) (P(i)/ATP) ratio, phosphocreatine (PCr)-ATP (PCr/ATP) ratio, P(i)/PCr ratio, muscle pH at resting and at end-exercise ( 31)P MR spectroscopy, rate constant for PCr recovery (k(PCr)), and maximum oxidative capacity (V(max)). These variables were also compared in MG patients before and after thymectomy (Wilcoxon signed rank test).There were no significant differences in resting P(i)/ATP, PCr/ATP, and P(i)/PCr ratios and resting muscle pH among the three groups (control group, 14; mild-MG group, nine; moderate-to-severe-MG group, seven). Comparison of the control group with the mild-MG group and comparison of the mild-MG group before thymectomy with the mild-MG group after thymectomy showed no significant differences in end-exercise P(i)/ATP, PCr/ATP, and P(i)/PCr ratios; end-exercise muscle pH; k(PCr); and V(max). Compared with the control and mild-MG groups, the moderate-to-severe-MG group had significantly higher end-exercise P(i)/ATP and P(i)/PCr ratios and significantly lower end-exercise muscle pH, k(PCr), and V(max) before thymectomy (Por = .001), but these values showed significant restoration to normal after thymectomy (P = .018).Mild-MG group patients have muscle oxidative metabolism similar to that of healthy control subjects, whereas moderate-to-severe-MG group patients have impaired V(max) during exercise and a noticeable shift to glycolytic metabolism, but these abnormalities are reversible after thymectomy.

Objective To report the clinical and computed tomographic findings of 5 cases of left brachiocephalic vein perforation (LBCVP). Methods The clinical and imaging features of 5 patients with LBCVP (1 woman, 4 men; mean age, 57.6 years) encountered over the last 2 decades were reviewed. Results Etiologies included left jugular central catheter penetration in 2 patients, blunt trauma in 2, and idiopathic in 1. All patients manifested acute chest pain with a widened mediastinum on chest radiographs. Characteristic computed tomographic features included a cord-like hematoma along the course of the left brachiocephalic vein associated with a left upper anterior mediastinal hematoma (AMH). Three clinically stable patients with AMH smaller than 5 cm convalesced after conservative treatment and 2 clinically unstable patients with AMH bigger than 7 cm recovered well after surgery. Conclusions Computed tomography is helpful in diagnosing LBCVP. Under close surveillance, patients with stable LBCVP with AMH smaller than 5 cm may be managed conservatively. However, emergency surgery is warranted if there are any signs of instability.

A 65-year-old woman with ocular myasthenia was found to have three tumours in the anterior mediastinum, revealed by magnetic resonance imaging. All three lesions were radically resected. Histologically, one was a mixed-type thymoma, one a thymic lymphoepithelioma-like carcinoma, and the third had features of both these types. This appears to be the first reported case of coexisting thymic lymphoepithelioma-like carcinoma (TLC) and thymoma associated with ocular myasthenia.

A 42-year-old man presented with a two-year history of progressive dysphagia and hoarseness. Esophagogram and endoscopy revealed submucosal mass effect on the upper esophagus. Computed tomography and magnetic resonance imaging revealed an elongated mass in the retrotracheal region of the lower neck with extension to the posterior mediastinum. Partial tumor resection and histopathological evaluation revealed a WHO type B2 thymoma. Adjuvant radiation and chemotherapy were subsequently administered resulting in complete tumor regression. To our knowledge, this is the first report of ectopic retrotracheal thymoma with clinical and imaging manifestations mimicking those for esophageal submucosal tumor.

Hydrothorax developing from pleuroperitoneal communication as a complication of peritoneal dialysis was first described in 1967 [Edward SR, Unger AM. Acute hydrothorax-a new complication of peritoneal dialysis. JAMA 1967; 199:853-5. ]. The incidence of hydrothorax is approximately 1.6-2% of continuous ambulatory peritoneal dialysis (CAPD) patients. The key to successful therapy is obliteration of the transdiaphragmatic route of dialysate leakage with video-assisted thoracoscopic surgery (VATS). The method in which air leakage is checked intraoperatively is the preferred choice and better than all other procedures.

A sutureless ringed intraluminal graft has been used as a substitute for the diseased aorta with the advantage of decreasing the aortic cross-clamp time and blood loss. Concerns remain about implications of anecdotal accounts of late complications with this graft. We report on the experience of a 68-year-old man, successfully treated for type B aortic dissection using the sutureless technique, who developed a pseudoaneurysm and aortobronchial fistula over the distal anastomosis of the intraluminal graft 12 years after the operation.

A preliminary report is made on the use of videothoracoscopy to achieve pulmonary lobectomy in 16 patients, including 12 with centrally located pulmonary metastases and 4 with benign lesions (3 bronchiectases and 1 endobronchial hamartoma). Videothoracoscopy was performed on eight right-lower lobes, one middle lobe, two right-upper lobes, four left-lower lobes, and one left-upper lobe with a thoracoscope and conventional thoracic instruments. All patients received standard pulmonary lobe resection with lymph node clearance similar to that achieved with open thoracotomy. The mean operative time was 3 h (range, 2.5 to 4 h). Average blood loss was 100 mL and mean length of hospital stay was 6 days (range, 4 to 8 days). A combination of videothoracoscopy with use of conventional instruments resulted in similar performance but less chest wall interruption than in conventional pulmonary lobectomy. Videothoracoscopy showed safer and faster lung resection, which subsequently minimized the perioperative morbidity. Pain intensity was lessened, functional recovery was quicker, and hospital stays were shorter in the patients we reviewed.

Thymoliposarcoma is an exceedingly rare thymic neoplasm with only five reports in English literature to date. We report another patient, a 36-year-old male, who developed local recurrences 4-years after initial resection. The clinicopathologic features of the present and previously reports were compared with particular emphasis on their morphologic spectrum and differential diagnosis.

Background Castleman disease of the pleura is unusual, and we present our experience with eight surgically proven cases. Methods Between 1980 and 2002, 8 patients (7 women and 1 man; age range, 20 to 53 years; mean, 26.5 years) with surgically proven, pleural Castleman disease (six hyaline vascular type, one plasma cell type, and one mixed type) were encountered. Their clinical, imaging, and surgical findings were reviewed. Results Five patients were asymptomatic, 1 had dyspnea, 1 had cough, and 1 experienced chest discomfort. Chest radiography showed a well-circumscribed interlobar, cardiophrenic, or paraaortic mass in 6 patients, a massive effusion in 1, and a focal diaphragmatic bulge in 1. Six tumors showed varying degrees of contrast enhancement (10 to 95 HU; mean, 46 HU) on computed tomography. Three cases appeared as well-defined, heterogeneously hyperintense pleural masses on magnetic resonance imaging. The masses varied in size from 3 to 10 cm (mean, 5.2 cm). Five masses greater than 5 cm had prominent pleural arterial blood supply and severe adhesions requiring thoracotomy and resection of nearby structures for radical tumor excision. Blood loss from patients varied between 100 and 850 mL (mean, 620 mL). No tumor recurrence was noted during follow-up (range, 1 to 16 years; mean, 6.5 years). Conclusions Pleural Castleman disease predominately affects young women and manifests as a well-circumscribed mass with a varying degree of contrast enhancement on computed tomography and heterogeneity on magnetic resonance imaging. Tumors greater than 5 cm have profuse pleural blood supplies and severe adhesion necessitating open thoracotomy and resection of neighboring structures. Radical resection can produce a satisfactory outcome.

Explantation of a degenerated mitral bioprosthesis with reimplantation of a new bioprosthesis is time-consuming and can be associated with several life-threatening complications. We developed a technique to simplify this procedure and avoid the complications by attaching a new bioprosthesis supported by a pericardium-covered Dacron tube to the intact stent.

J Thorac Cardiovasc Surg 2002;124:194-5

Mediastinal mature teratoma (MMT) is an uncommon neoplasm in children, accounting for only 4.3% of all germ cell tumors. 1-3 It may cause stridor and dyspnea by direct tracheal compression in children

We operated on 403 patients with spontaneous pneumothorax between 1992 and 1996. Among these cases, 11 (2.7%) were spontaneous hemopneumothorax. The patients were all men, with ages ranging from 19 to 28 years (mean 23.8 years). The amount of blood drainage ranged from 650 to 2300 ml. Video-assisted thoracoscopic surgery was performed on these patients within 1 day after admission. The sources of bleeding were in the parietal and visceral pleurae of ruptured bullae (n = 6), the parietal pleura (n = 4), or the visceral pleura (n = 1). During operation, the ruptured bullae can be managed by an endoscopic linear stapler for a bullectomy, and the bleeding parietal pleura of the torn adhesion can be coagulated directly. Postoperative recovery of the 11 patients was uneventful, and they were discharged 4 to 10 days after the operation. No recurrence of spontaneous hemopneumothorax or any other complications occurred during follow-up. Thus spontaneous hemopneumothorax can be readily managed by cauterizing a bleeding site where appropriate, excising the apicocystic disease, and pleurodesis. As a minimally invasive method, video-assisted thoracoscopic surgery may be considered an initial treatment procedure in patients with spontaneous hemopneumothorax.

Magnetic resonance (MR) imaging features of 15 thoracic neurilemmomas were analyzed. Morphologically, five tumor patterns could be identified on MR imaging including: inhomogeneous masses (n = 8), thick-walled multiloculated masses (n = 2), thick-walled central cystic masses (n = 2), homogeneous cystic masses (n = 2) and a target pattern mass (n = 1). The signal characterization of thoracic neurilemmomas was variable, usually brighter on T2-weighted images, hyper- to hypo-intense on T1-weighted images and always enhancing. Histopathologically, the inhomogeneous masses were characterized by irregular distribution of hypercellular Antoni A and hypocellular Antoni B tissues with variable degrees of cystic, hemorrhagic, myxoid and hyaline degenerative changes. Enlargement of the cystic areas led to the development of thick-walled multiloculated masses while confluence of these cystic areas produced a central cystic pattern. Extensive myxoid or hyaline degeneration yielded homogeneous cystic tumors. Peripheral fibrinous changes and central Antoni B stroma contributed to a target pattern. Appreciation of the protean MR manifestations and understanding of the underlying histopathological changes of thoracic neurilemmomas are helpful in the diagnosis of this tumor.

Lung nodules in patients with a history of malignancy usually require tissue diagnosis that will provide prognostic information and dictate further therapy. Patients with a favorable tumor histologic condition and limited tumor burden were often considered for resection. This is usually accomplished by wedge resection through open thoracotomy when the lesions were peripheral. However, complications related to open thoracotomy often exclude poor-risk patients, especially those with impaired pulmonary function. Currently, technique of thoracoscopic resection is opening up new vistas and unimagined options for the thoracic surgeon in the management of pulmonary diseases. With the application of thoracoscopy and small incisions, it is now possible for the thoracic cavity and its contained organs to be thoroughly explored. Our recent experience with the thoracoscopic resection as a primary treatment for lung metastases is the focus of this report. Forty-seven patients with a history of malignancy and new lung metastases underwent this type of resection. Postoperatively, there is less pain, quick functional recovery, and excellent cosmetic healing. It is a safe and promising approach.

Video-assisted thoracoscopic technique was evaluated in 28 patients who underwent operation for massive pericardial effusion. Excellent results were obtained using this newly developed approach for inspection of all pericardial surfaces as well as pleural and pulmonary disorders. No perioperative or postoperative complications ensued. Videothoracoscopy revealed positive lung malignancies in 11 patients, and these would not have been promptly diagnosed without thoracoscopy. Thoracoscopy also confirmed metastatic deposits on the pleura and diaphragm in 4 other patients. The visible nodules were proved to be metastatic adenocarcinoma. In 13 patients, thoracoscopy did not reveal malignancy, although 2 of these patients had a clinically suspected malignant lung tumor. Other indications for thoracoscopic drainage included 2 patients with impending pericardial tamponade after heart procedures and 6 patients with recurrent/loculated pericardial effusion. All of the patients showed promising and favorable postoperative courses after thoracoscopy. From our experience, video-assisted thoracoscopy was a safe and effective procedure, especially for those patients with combined pericardial effusion and abnormal pulmonary or pleural pathology in whom subxiphoid pericardial window was not clearly diagnostic at the time of operation. It was effective also in the situation with recurrent or loculated pericardial effusion which allowed localization and drainage of it. We believe that the use of videothoracoscopy to visualize the whole pericardial and pleural cavity will continue to be of great benefit to patients with combined pericardial and pleural/lung diseases.

The search for an ideal mitral valve substitute continues. Ross1 described the use of a pulmonary autograft for mitral valve replacement in 1967, and this operation is only now being reappraised because of its many advantages.2,3 In patients with irreparable mitral valvulopathy complicated with chronic atrial fibrillation, addition of some sort of ablative procedure has been recommended to make its benefits more complete.4 Currently, a stentless bioprosthesis is accepted as the right ventricular outflow tract (RVOT) substitute of choice in the Ross procedure.4,5 We report on 2 patients who had satisfactory results with the use of a Freestyle aortic root bioprosthesis (Medtronic, Inc, Minneapolis, Minn) for RVOT reconstruction in the Ross II procedure combined with the radiofrequency maze IV procedure that was developed in our center.6,7

The internal mammary artery (IMA) has become the conduct of choice for coronary artery bypass grafting. However, the IMA graft can exhibit vasoconstriction during the perioperative period. Experiments were designed to determine the role of cyclooxygenase products in human IMA during hypoxia. Rings of IMA, with and without endothelium, were suspended in organ baths containing physiologic salt solution. Rings were contracted with norepinephrine and then exposed to hypoxia for 15 minutes. In segments with endothelium, hypoxia induced a transient relaxation followed by contraction. This contraction was associated with a significantly increased production of thromboxane B2, the stable metabolite of thromboxane A2 (n = 10; from 120.7 +/- 3.5 pg/mg wet tissue before hypoxia to 175.8 +/- 5.2 pg/mg during hypoxia; p0.05). This hypoxic contraction could be attenuated by indomethacin. However, thromboxane B2 could not be detected in samples from organ baths containing IMA segments without endothelium before or during hypoxia. This study demonstrated that endothelium of human IMA grafts releases thromboxane A2 basally and that production is augmented by hypoxia, which acts to constrict the underlying vascular smooth muscle, increase vascular tone, and promote ischemic events such as vasospasm and thrombosis, particularly in hypoxemic patients.

Thrombotic obstruction, a rare but often fatal complication of cardiac valve prostheses, appears to occur more frequently in tilting-disc valves than in other valve designs. Its diagnosis and surgical treatment remain a challenge. Ten consecutive patients who had thrombosis of a tilting-disc valve prosthesis were treated in Chang Gung Memorial Hospital from November 1982 to August 1990. Preoperative clinical features, including exertional dyspnea, new murmur, and absence of a metallic click from the prosthetic valve, occurred in all of the patients. Symptoms were present for 1 week or more before reoperation in 70% of the patients; nevertheless, many patients were referred only after acute exacerbation of heart failure and development of pulmonary edema. Echocardiography confirmed prosthetic valve malfunction in 90% of the patients. One unconfirmed case was later documented by cardiac catheterization. Anticoagulant therapy was in the therapeutic range for only half of the patients at the time of admission. Prompt reoperation was performed for thrombectomy (8 patients, all survived) or valve replacement (2 patients, one death). Long-term outcome was satisfactory in all survivors with a mean follow-up of 31.6 months. These findings emphasize the importance of considering the diagnosis of thrombosis in patients with mechanical heart valve prostheses who are first seen with nonspecific symptoms and minor changes of their physical findings. The diagnosis could be easily made by echocardiography. Thrombectomy is an easy, fast, and safe procedure, especially for these critically ill patients.

Perforation of the thoracic esophagus can be fatal unless diagnosed promptly and treated effectively. The high mortality with delayed treatment is due principally to an inability to effectively close the perforation and prevent leakage. From 1982 to 1988, 7 consecutive patients (aged 16 to 73 years) were treated after a delayed diagnosis (26 hours to 25 days) of thoracic esophageal perforation. In all patients, the perforation was closed after debridement with total exclusion of the esophagus (T-tube cervical esophagostomy plus absorbable ligatures applied to the esophagogastric junction and the cervical esophagus distal to the esophagostomy). Radical decortication and wide mediastinal and pleural drainage were also done. Nutritional supply was given through a feeding gastrostomy. Antibiotics were administered according to the results of cultures. All patients survived. Continuity of the esophagus was established by removal of the T tube and spontaneous absorption of the ligatures. Endoscopy and esophagography performed 4 weeks after the initial operation showed a well-healed esophagus without stenosis or leakage in all patients. No secondary thoracotomy or esophageal reconstruction was necessary. No dysphagia was noted during follow-up (range, 12 to 50 months; mean follow-up, 23 months). We conclude that primary closure of the perforation and total esophageal exclusion with the use of absorbable ligatures and T-tube esophagostomy can provide a one-stage operation with good results for repair of thoracic esophageal perforation diagnosed late.

Objective Congenital heart diseases in pediatric patients are associated with a wide variety of extracardiac thoracic vascular abnormalities. This study analyzed the value of gadolinium-enhanced magnetic resonance angiography during quiet free breathing for assessing extracardiac thoracic vascular abnormalities in young children with congenital heart diseases. Methods Fifty-three children with congenital heart diseases (age range, 1 day-40 months; mean, 10.9 months) associated with extracardiac thoracic vascular abnormalities who had undergone both free-breathing, gadolinium-enhanced magnetic resonance angiography and cardiac catheterization, surgical intervention, or both within 2 weeks were reviewed. Diagnostic findings on gadolinium-enhanced magnetic resonance angiography among patients grouped according to 3 major conditions of conotruncal abnormalities (n = 33), aortic or venous abnormalities (n = 11), and pulmonary vascular abnormalities (n = 9), as well as associated extracardiac thoracic vascular abnormality findings, were compared with findings made by using cardiac catheterization, surgical intervention, or both. Results Extracardiac thoracic vascular abnormality findings on gadolinium-enhanced magnetic resonance angiography were similar to those on catheterization, surgical intervention, or both in patients with conotruncal abnormalities (124 vs 127, P = .083), aortic or venous abnormalities (36 vs 33, P = .083), and pulmonary vascular abnormalities (24 vs 25, P = .317). The overall sensitivity of gadolinium-enhanced magnetic resonance angiography for detection of these lesions identified by means of catheterization, surgical intervention, or both was 97.9%. However, gadolinium-enhanced magnetic resonance angiography revealed 11 additional extracardiac thoracic vascular abnormalities that were not found on cardiac catheterization. The κ coefficient for the correlation of image quality and diagnostic value of gadolinium-enhanced magnetic resonance angiography by using a 4-point-scale (1 = nondiagnostic to 4=excellent) assessed by 2 independent reviewers was excellent (mean score=3.66), with superb interobserver agreement (κ = 0.727-0.874). Conclusions Free-breathing, gadolinium-enhanced magnetic resonance angiography is clinically feasible for detailed anatomic delineation and treatment planning of various extracardiac thoracic vascular abnormalities in young children with congenital heart diseases.

Surgeons who have gained experience and confidence with video-assisted thoracic surgery are now routinely applying the minimally invasive approach to treat patients with spontaneous pneumothorax. Although the endoscopic stapling device may be a preferred method for resection of parenchymal blebs or bullae, the stapling device is not inexpensive. In an effort to contain costs since we started performing the video-assisted thoracoscopic procedure in chest surgical diseases, we have used a self-made endoscopic loop as an alternative method. It has assisted us in performing bulla ablation in a cost-effective manner. Over a 4-year period (1992 to 1996), we assessed the efficacy of ligating parenchymal blebs and bullae with a self-made endoscopic loop by video-assisted techniques. A total of 263 ligations were performed in 250 patients. Surgical indications included recurrence (n = 146), bilaterality of the disease (n = 13), hemopneumothorax (n = 7), radiologically demonstrated large bulla (n = 9), persistent air leak (n = 52), and nonexpansion of the lung (n = 23). There were no operative deaths. Early postoperative complications included a dislodged endoscopic loop necessitating reexploration in one patient and postoperative minor wound infections in 13. The average postoperative hospitalization was 4.5 days. Two hundred seventeen patients (86.8% of all patients) were followed up for a median of 28 months (1 to 46 months) after the operation. There have been no recurrences to date. Our results showed that thoracoscopic loop ligation is safe and effective in managing blebs and parenchymal bullae, with a lower cost, fewer complications, and a lower recurrence rate than provided by standard surgical techniques. On the basis of our results, we advocate the use of the self-made endoscopic loop for ligation of parenchymal blebs and bulla in patients with spontaneous pneumothorax to achieve a truly cost-effective and minimally invasive thoracoscopic procedure. (J Thorac Cardiocasc Surg 1997:113:50-4)

One hundred and fifty four consecutive adult patients having cardiac surgery for a variety of cardiac lesions were evaluated prospectively for postoperative jaundice, those with a raised preoperative serum bilirubin concentration (greater than 34 mumol/l or 2 mg/100 ml) being excluded. The incidence of early postoperative jaundice, as defined by a serum bilirubin concentration of 50 mumol/l (3.0 mg/100 ml) or greater, was 23.4%. The jaundice was mild (bilirubin concentration 51-100 mumol/l (3.0-6.0 mg/100 ml] in 26 patients (16.9%) and moderate to severe (greater than 100 mumol/l (6.0 mg/100 ml] in 10 patients (6.5%). Important contributing factors were the preoperative severity of right heart failure (raised right atrial pressure at heart catheterisation) and hypotension or hypoxaemia and the amount of blood transfused during or shortly after surgery. Age, sex, underlying cardiac lesion, whether halothane was used, operative procedure, duration of cardiopulmonary bypass, and presence or absence of hepatitis B surface antigen were not predictive of postoperative jaundice.