Hye-seon Kim

Early clinical outcomes of robot-assisted surgery for anterior mediastinal mass: its superiority over a conventional sternotomy approach evaluated by propensity score matching

OBJECTIVES We performed this study to assess early clinical outcomes of robot-assisted surgery for anterior mediastinal mass by comparing results of the robot group with those of the sternotomy group after propensity score matching. METHODS Between 2008 and 2012, 145 patients underwent resection of anterior mediastinal mass. Robot-assisted surgery was performed in 37 patients, and conventional surgery by sternotomy in 108 patients. Propensity score matching was done between two groups with variables of age, sex, size of the mass, myasthenia gravis, resection of other organ and pathological diagnosis. Thirty-four patients from the robot group and 34 from the open group were matched, fitting the model. The clinical outcomes of matched groups were compared. RESULTS In the robot group, mediastinal cyst consisted of 47.1% (16 of 34), thymoma 32.4% (11 of 34), thymic carcinoma 8.8% (3 of 34), thymic hyperplasia 8.8% (3 of 34) and liposarcoma 2.9% (1 of 34). The mean duration of follow-up was 1.11 ± 0.21 and 1.85 ± 0.19 years for the robot and open groups, respectively. There were no mortality or recurrence in both groups during the follow-up. There were no significant differences in operation time, postoperative white blood cell and C-reactive protein increase, maximum visual analogue scale score for pain as well as postoperative intensive care unit care between the two groups. The robot group revealed a lesser number of drains (1.09 ± 0.1 vs 1.41 ± 0.1) and 24-h tube drainage (189.4 ± 20.5 vs 397.6 ± 52.6 ml), lower haemoglobin loss (0.54 ± 0.4 vs 1.35 ± 0.1 g/dl) and haematocrit decrease (1.92 ± 0.5 vs 3.85 ± 0.4%), shorter chest tube days (1.53 ± 0.2 vs 3.06 ± 0.2) and length of hospital stay (2.65 ± 0.2 vs 5.53 ± 0.8) after operation, which were all statistically significant. Although statistically insignificant, there were no postoperative complications in the robot group, but there were 5 (14.7%) in the open group (P = 0.063). CONCLUSIONS In carefully selected patients with relatively smaller sized masses, robot-assisted surgery resulted in excellent early clinical outcomes with lesser tube drainage, lower blood loss, shorter tube days and length of hospital stay without any postoperative complications, compared with the matched open group. Further investigation for long-term clinical outcomes and oncological outcomes is required for a robotic approach. Particularly, long-term follow-up for the local recurrence rate according to the pathological diagnoses is required.

Video-assisted thoracoscopic lobectomy in non-small-cell lung cancer patients with chronic obstructive pulmonary disease is associated with lower pulmonary complications than open lobectomy: a propensity score-matched analysis

OBJECTIVES Non-small-cell lung cancer (NSCLC) patients with chronic obstructive pulmonary disease (COPD) are at an increased risk of pulmonary complications after pulmonary resection. This study aimed to identify whether video-assisted thoracoscopic (VATS) lobectomy can reduce postoperative pulmonary complications compared with lobectomy by thoracotomy in NSCLC patients with COPD. METHODS Among a total of 1502 NSCLC patients who underwent lobectomy from April 2005 to June 2012 at the Seoul National University Hospital, 446 (29.7%) were diagnosed with COPD based on the spirometric criteria of the Global Initiative for COPD. Among the 446 patients, 283 presented with stage I NSCLC and were selected for this study. The study patients were divided into two groups: patients undergoing VATS (n = 160) lobectomy and patients undergoing thoracotomy (n = 123) lobectomy. A propensity analysis that incorporated preoperative variables, such as age, sex, Charlson comorbidity index, extent of smoking, preoperative pulmonary function, size of the mass, histological type of the tumour and additional lung resection, was performed, and postoperative outcomes were compared. RESULTS Matching based on propensity scores produced 91 patients in each group for the analysis of postoperative outcomes. There were only three operative mortalities in the thoracotomy group, and all of these patients died of postoperative pneumonia. The overall incidence of postoperative complications was 32.9% (30 of 91) and 22.0% (20 of 91) in the thoracotomy group and in the VATS group, respectively (P = 0.14). Compared with lobectomy by thoracotomy, VATS lobectomy was associated with a lower incidence of pulmonary complications (1.1 vs 12.1%; P < 0.01), shorter operation time (165 vs 201 min; P < 0.01) and shorter length of stay (6.0 vs 9.0 days; P = 0.04). CONCLUSIONS VATS lobectomy is associated with a lower incidence of pulmonary complications compared with lobectomy by thoracotomy in stage I NSCLC patients with COPD. VATS lobectomy may be the preferred strategy for appropriately selected NSCLC patients with COPD.

Importance of lymph node dissection in thymic carcinoma.

BACKGROUND Lymph node dissection plays important role in oncologic surgery. We investigated outcomes of lymph node dissection in thymic carcinoma. METHODS We retrospectively reviewed 37 patients, who underwent complete resection for thymic carcinoma. Patients were divided into four groups: no node dissection (Nx), 8; pathologic N0 by limited dissection (N0a), 13; pathologic N0 by extensive dissection (N0b), 10; and node metastasis (N1), 6. Outcomes of lymph node dissection were investigated. Disease-free survival (DFS) and freedom from recurrence of the four groups were compared. RESULTS A total of 349 lymph nodes were dissected in 29 patients. Metastasis was confirmed in 19 nodes in 6 patients, with tumor invading adjacent organs. Anterior mediastinal lymph node metastasis was confirmed in 4 patients. Intrathoracic lymph node metastasis was confirmed in 3 patients at the right paratracheal lymph nodes. Recurrences were diagnosed in 11 patients (Nx, 2; N0a, 4; N0b, 1; N1, 4). The 5-year overall survival rate was 65.5%, DFS was 60.9%, and freedom from recurrence was 68.2%. DFS rates of the N0b subgroup were significantly better than in the N1 subgroup (90% vs 33.3%). DFS rates of the Nx and N0a subgroups were similar (75% vs 48.7%, p=0.98), and the prognoses of both groups were intermediate between the N0b and N1 groups. Analyses of freedom from recurrence proved identical results. CONCLUSIONS Extensive lymph node dissection, meaning dissection of more than 10 lymph nodes, is required to predict prognosis accurately. Anterior mediastinal and right paratracheal lymph nodes should be dissected in thymic carcinoma.

Prognostic and predictive role of epidermal growth factor receptor mutation in recurrent pulmonary adenocarcinoma after curative resection

OBJECTIVES Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) treatment prolongs the progression-free survival of patients with advanced non-small-cell lung cancer harbouring EGFR mutations. This study aimed to evaluate the prognostic factors influencing survival after recurrence, and the effectiveness of EGFR-TKIs in patients with recurrent pulmonary adenocarcinoma after curative resection. METHODS EGFR mutations were prospectively evaluated in 594 patients who underwent curative surgical resection for pulmonary adenocarcinoma. Among them, 138 patients who had postoperative recurrent disease were enrolled in the study. Potential prognostic factors for post-recurrence survival (PRS) were evaluated, and predictive factors of responsiveness to EGFR-TKIs were also analysed. RESULTS Among the 138 patients who had postoperative recurrent disease, EGFR mutations were identified in 73 (52.9%) patients. In multivariable analysis, never-smoking status [hazard ratio (HR), 0.522; P = 0.012], adjuvant radiotherapy (HR, 1.995; P = 0.016), disease-free interval of less than 1 year from initial resection to recurrence (HR, 2.382; P = 0.001), surgical treatment for recurrence (HR, 0.346; P = 0.002) and EGFR mutation (HR, 0.552; P = 0.013) were independent prognostic factors for PRS. Among patients treated with EGFR-TKI, EGFR mutation status was the only predictor of response to EGFR-TKI (P < 0.001), and patients with EGFR mutation showed better PRS (3- and 5-year survival rates after recurrence, 68.8 and 41.1%, respectively) than those without EGFR mutations (3- and 5-year survival rates after recurrence, 39.1 and 15.7%, respectively; P = 0.017). CONCLUSIONS Our study demonstrated that EGFR mutation is an independent prognostic factor for PRS. Considering that EGFR mutations were the only independent predictors for response to EGFR-TKIs, selecting patients for EGFR-TKI therapy according to EGFR mutation status may lead to a better prognosis in patients with recurrent pulmonary adenocarcinoma.

The role of preoperative bone scan for determining the treatment method for femoral neck fracture

To evaluate the role of preoperative bone scintigraphy in determining the operative treatment method for femoral neck fracture, we reviewed the data of 83 patients who underwent preoperative bone scanning after femoral neck fracture. Fractures were classified using the Garden staging system. Radioisotope uptake in femoral heads was evaluated visually. Of 28 patients with Garden stage I or II, radioactivity of the femoral head was normal in 26, partially reduced in one, and generally reduced in one patient. Twenty-seven patients were treated by closed reduction and multiple pinning, and one patient was treated by bipolar hemiarthroplasty. Of 55 patients with Garden stage III or IV, femoral-head radioactivity was normal in three, partially reduced in seven and generally reduced in 45 patients. Fifty-four patients were treated by bipolar hemiarthroplasty or total hip arthroplasty, and one patient was treated by closed reduction and multiple pinning. In only one of the 83 cases was the operative method changed because of bone scan findings. Isotope uptake of the femoral head after femoral neck fracture generally corresponded with the degree of fracture displacement. Preoperative bone scans appear to have no significant role to play in determining the operative treatment method for femoral neck fracture.RésuméAfin d’évaluer le rôle préopératoire de la scintigraphie osseuse dans les fractures du col du fémur, nous avons revu les dossiers de 83 patients qui ont présenté une fracture du col fémoral. La fracture a été classée selon la classification de Garden. Sur les 28 patients Garden I et II, la réponse scintigraphique de la tête fémorale est normale pour 26 patients, avec une hypofixation osseuse pour un patient et une fixation peu importante chez un autre patient. 27 patients ont été traités par réduction orthopédique et embrochage à foyer fermé, un patient par hémiarthroplastie. Pour les 55 patients présentant une fracture Garden III ou IV, la scintigraphie de la tête fémorale a été normale chez trois patients avec une hypofixation chez 7 patients, une fixation très réduite chez 45 patients. 54 patients ont été traités par hémiarthroplastie ou par prothèse totale et un patient traité par réduction orthopédique et embrochage. Chez un seul des 83 patients, la méthode opératoire a été changée après les constatations scanographiques. La fixation isotopique après fracture du col fémoral correspond tout à fait au degré et au déplacement de la fracture. Le scanner préopératoire ne semble pas avoir d’intérêt pour déterminer le traitement optimum chez ces patients.

Reverse V-Shape Kinking of the Left Lower Lobar Bronchus after a Left Upper Lobectomy and Its Surgical Correction

A 76-year-old male underwent a left upper lobectomy with wedge resection of the superior segment of the left lower lobe using video-assisted thoracoscopic surgery (VATS) for non-small-cell lung cancer of the left upper lobe. He presented with shortness of breath, fever, and leukocytosis. Chest radiography showed atelectasis at the remaining left lower lobe. Bronchoscopy revealed narrowing of the left lower bronchus with purulent secretion, and computed tomography showed downward kinking of the left lower lobar bronchus. He underwent exploratory VATS, and intraoperative findings showed an inferiorly kinked left lower lobar bronchus with upward displacement of the left lower lobe. After adhesiolysis, the kinked bronchus was straightened, and bronchopexy was performed to the pericardium to prevent the recurrence of bronchial kinking. Also, the inferior pulmonary ligament was reattached to prevent upward displacement. Postoperative follow-up bronchoscopy revealed no evidence of residual bronchial obstruction, and chest radiography showed no atelectasis thereafter.

Left Ventricular Pseudo-pseudoaneurysm with Hemopericardium.

We report a case of pseudo-pseudoaneurysm, which is a very rare complication of myocardial infarction. A 69-year-old man was admitted to our clinic with chest tightness and dyspnea. He had undergone aortic valve replacement with a pericardial bioprosthetic valve, ring mitral annuloplasty, and reconstruction of an aortic annular defect due to infective endocarditis with bovine pericardium 4 years prior. Echocardiography and computed tomography showed pericardial effusion and a 16-mm cavity at the anterolateral wall of the left ventricle. Magnetic resonance imaging suggested either pseudo-pseudoaneurysm or myocardial abscess. We successfully repaired the myocardial defect using a patch made from a vascular graft with pledgeted horizontal mattress sutures under cardiopulmonary bypass.

Intrapericardial Implantation of an Implantable Cardioverter-Defibrillator in a Child

Implantable cardioverter defibrillator (ICD) can be a crucial therapeutic modality for pediatric patients with congenital heart disease, Brugada syndrome, long QT syndrome and cardiomyopathy. Because transvenous implantation of ICD is mostly unfeasible for pediatric patients due to anatomical and technical limitations, epicardial patch type or subcutaneous type ICD have been used. Implantation of these alternative ICDs, however, was reported to be frequently associated with significant complications. We report a case of successful intrapericardial implantation of a single coil-type ICD through the transverse sinus in a 27 month-old child weighing lesser than 10 kg, and it was inferred from this experience that this alternative technique may decrease complications and morbidities after ICD implantation in children.

Natural History of Ground-Glass Nodules Detected on the Chest Computed Tomography Scan After Major Lung Resection

BACKGROUND Detection of ground-glass nodules (GGNs) on computed tomography (CT) is increasing due to advances in CT technology and the findings of the National Lung Screening Trial. Ground-glass nodules are detected on screening chest CTs and CT scans after lung resection surgery. It is important to investigate the natural history of GGNs as it is not yet well known, and a standardized approach to manage them has not been established. METHODS We selected patients who presented with GGNs on chest CT taken after major lung resection. One hundred thirty-nine GGNs were detected in 92 patients and followed up for longer than 1 year. Characteristics of GGN, size, presence of a solid component and multiplicity, and demographic data of patients such as history of smoking and malignant disease were analyzed to identify factors that affected GGN growth. RESULTS During the follow-up period (mean 44.4 months), 23 GGNs showed a significant increase in size. The only predictor for the growth of GGNs was the presence of a solid component (p < 0.001). Pathologic diagnosis was made in 14 patients. Of those, 10 GGNs including 7 primary lung adenocarcinomas were diagnosed as malignant. Three of 4 benign lesions were diagnosed as atypical adenomatous hyperplasia. There were no mortalities directly related to GGNs. CONCLUSIONS In GGNs detected on CT scans of patients who had undergone major lung resection, the presence of a solid component was the only factor that could predict nodule growth. Although the majority of growing GGNs were adenocarcinoma, the clinical course seemed to be indolent.

Subxiphoid Incisional Hernia Development after Coronary Artery Bypass Grafting

Background Median sternotomy can weaken the upper abdominal wall and result in subxiphoid incisional hernia. We evaluated risk factors associated with the development of subxiphoid incisional hernias after coronary artery bypass grafting (CABG). Materials and Methods Of 1,656 isolated CABGs performed between January 2001 and July 2010, 1,599 patients who were completely followed up were analyzed. The mean follow-up duration was 49.5±34.3 months. Subxiphoid incisional hernia requiring surgical repair developed in 13 patients (0.8%). The hernia was diagnosed 16.3±10.3 months postoperatively, and hernia repair was performed 25.0±26.1 months after the initial operation. Risk factors associated with the development of subxiphoid incisional hernia were analyzed with the Cox proportional hazard model. Results Five-year freedom from the hernia was 99.0%. Univariate analysis revealed that female sex (p=0.019), height (p=0.019), body surface area (p=0.046), redo operation (p=0.012), off-pump CABG (p=0.049), a postoperative wound problem (p=0.041), postoperative bleeding (p=0.046), and low cardiac output syndrome (p<0.001) were risk factors for the development of the hernia. Multivariable analysis showed that female sex (p=0.01) and low cardiac output syndrome (p<0.001) were associated with subxiphoid hernia formation. Conclusion Female sex and postoperative low cardiac output syndrome were risk factors of subxiphoid hernia. Therefore, special attention is needed for patients with high-risk factors.