Innes Yp Wan

Impact of Video-Assisted Thoracoscopic Major Lung Resection on Immune Function

Video-assisted thoracoscopic major lung resection for early stage non-small-cell lung carcinoma has been associated with less postoperative pain, better preserved pulmonary function, shorter hospital stay, and enhanced tolerance of adjuvant chemotherapy compared to thoracotomy. Initial concerns regarding safety, oncological clearance, and cost effectiveness were unfounded. Several recent trials have reported improved long-term survival in patients with early stage non-small-cell lung carcinoma undergoing video-assisted thoracoscopic major lung resection, compared to the open technique, although there are inconsistencies. Interestingly, the immune status and autologous tumor killing ability of lung cancer patients have previously been associated with long-term survival. Video-assisted thoracoscopic lung resection results in an attenuated postoperative inflammatory response, but more importantly, it better preserves postoperative immune function. Circulating natural killer and T-cell numbers, T-cell oxidative activity, and levels of immunochemokines such as insulin growth factor binding protein-3 are higher after video-assisted thoracoscopic surgery than after thoracotomy. Recently, interest has developed in the role of the angiogenesis factor, vascular endothelial growth factor, after cancer surgery. Whether differences in immunological and biochemical mediators contribute towards improved long-term survival following video-assisted thoracoscopic major lung resection for cancer remains to be confirmed.

Robot-assisted excision of ectopic mediastinal parathyroid adenoma.

Robot-assisted excision of an ectopic parathyroid adenoma in the superior mediastinum was performed in a 57-year-old man. The mass was located by methoxyisobutylisonitrile scan and computed tomography. Identification of the ectopic parathyroid adenoma was facilitated by the 3-dimensional images of the da Vinci robotic system, and resection was achieved using EndoWrist instruments. Robot-assisted excision of parathyroid adenoma located in the relatively inaccessible superior mediastinum proved to be feasible.

Recurrent hemoptysis with Penicillium marneffei and Stenotrophomonas maltophilia in Job's syndrome

Pulmonary infection caused by the opportunistic organisms Penicillium marneffei and Stenotrophomonas maltophilia in patients with Jobs syndrome is rare and not well documented. The case of a 30-year-old man with Jobs syndrome who developed recurrent pneumonia and lung abscesses caused by P. marneffei and S. maltophilia, complicated by massive hemoptysis, is described. Bronchial artery embolization was successful in controlling the hemoptysis; however, the infection proved fatal despite appropriate antimicrobial therapy. A brief review of the literature on Jobs syndrome and its associated infective pulmonary manifestations is also presented.

Video-Assisted Thoracic Surgery Excision of Mediastinal Hemangioma

A 62-year-old woman with a middle mediastinal hemangioma was successfully treated using a video-assisted thoracic surgery approach facilitated by segmental rib resection, despite an initial radiological study that showed encasement by the surrounding great vessels. Pathological examination confirmed a cavernous hemangioma. This approach offers potential resection in difficult cases of mediastinal tumor.

Is hyperamylasemia after cardiac surgery due to cardiopulmonary bypass

Although hyperamylasemia has been reported in a large proportion of patients undergoing cardiac surgery with cardiopulmonary bypass, its clinical significance and pathogenetic mechanisms remain poorly understood. The study was designed to investigate whether avoidance of cardiopulmonary bypass would limit amylase elevation. Serum levels of amylase and lipase were measured preoperatively as well as 24 and 48 hours postoperatively in 58 patients undergoing elective coronary artery bypass grafting. Three surgical approaches were used: cardiopulmonary bypass (n = 32) and off-pump through a median sternotomy (n = 14) or a left minithoracotomy (n = 12). There was no hospital mortality or postoperative abdominal complications. Transient hyperamylasemia occurred in 14 patients: 7 (22%), 5 (36%), and 2 (17%) in the respective groups. The increase in amylase levels was similar among the groups. However, no lipase elevation was detected in any patient. There was no clear correlation between hyperamylasemia and increased creatinine levels. Perioperative plasma calcium levels were normal in patients who had hyperamylasemia. Our results indicate that hyperamylasemia after bypass surgery is not related to the use of cardiopulmonary bypass or the mode of surgical access.

Mediastinal follicular dendritic cell sarcoma with paraneoplastic pemphigus

Follicular dendritic cell sarcoma is a rare neoplasm of immune accessory cells. It occurs primarily in lymph nodes. Occurrences in the mediastinum are rarely reported. Diagnosis and management of follicular dendritic cell sarcoma remain unclear, and it is an under-recognized clinical entity. Only a few cases of paraneoplastic pemphigus as the first presentation of follicular dendritic cell sarcoma have been reported. We report an unusual case of follicular dendritic cell sarcoma of the anterior mediastinum, presenting as paraneoplastic pemphigus in a 62-year-old man. Typical histological features confirmed the diagnosis of follicular dendritic cell sarcoma, and surgical resection was successfully performed.

Mitral valve repair using a semirigid ring: patient selection and early outcomes

Background Commonly used complete mitral annuloplastic rings include saddle-shaped and semirigid rings, with no clear indication for either type. A semirigid ring may be preferred in patients whose native mitral saddle shape is well maintained. We present our experience of using semirigid rings for mitral valve repair. Methods We routinely measured the annular height-to-commissural width ratio by 3-dimensional transesophageal echocardiography prior to mitral repair. We generally chose a semirigid (Memo 3D) ring in patients whose annular height-to-commissural width ratio was normal (≥ 15%). The same semirigid ring with an additional chordal guiding system (Memo 3D ReChord) was selected for patients with anterior leaflet or bileaflet pathology. Over an 18-month period, 66 patients with severe degenerative (nu2009=u200960) or functional (nu2009=u20096) mitral regurgitation had Memo 3D (nu2009=u200932) or Memo 3D ReChord (nu2009=u200934) rings implanted. Results Postoperative 3-dimensional transesophageal echocardiography was completed in all patients (mean follow-up 7u2009±u20095 months). The majority of patients had no or mild residual mitral regurgitation; only two had moderate (2+) mitral regurgitation. There was no mortality at 30-days or on midterm follow-up. Conclusions Our series represents the first Asian clinical experience using the Memo 3D ReChord ring. Although the long-term durability of mitral repair with this type of semirigid annuloplastic ring warrants further validation, our current clinical data are encouraging.

Actinomycosis: an often forgotten diagnosis.

We report a case of actinomycosis presenting as a chest wall mass in a 35 year-old man. Thoracic actinomycosis poses a diagnostic challenge to clinicians not only because it is uncommon and often forgotten, but also because culture of the causative microbes is technically difficult. The classic microscopic appearance of this Gram-positive bacteria associated with surrounding sulfur granules often forms the basis of diagnosis.

Ruptured pulmonary arteriovenous malformation during pregnancy

Pulmonary arteriovenous malformation (PAVM) during pregnancy is a rare condition. There were 34 cases reported in the literature of which three were fatal. The major cause of death was pulmonary hemorrhage. Physiological changes during pregnancy can worsen PAVM and can increase its risk of hemorrhage. The mechanism can be twofold. High estrogen and progesterone levels during pregnancy lead to venous distensibility and hence trigger the growth of PAVM whereas the increase in blood volume and cardiac output could raise the pulmonary blood flow and could cause dilatation and rupture of the thin-walled vessels. This explains that the majority of the hemorrhage occurs during the second and third trimesters when blood volume and cardiac output increased to their maximum. We describe a case of hemothorax as a result of ruptured PAVM and discuss its management during pregnancy. (excerpt)

Staphylococcus aureus pancarditis complicated by a left ventricular pseudoaneurysm.

Acute septic pancarditis is a life threatening but fortunately rare condition. We report a case of this condition in a young 20-year-old female patient with an early complication of mitral valve destruction and a late complication of a left ventricular pseudoaneurysm formation.