Jeong Su Cho

Thoracoscopic Primary Esophageal Repair in Patients With Boerhaave's Syndrome

BACKGROUND Early diagnosis and appropriate treatment are important for a good outcome in Boerhaaves syndrome. The results of recent studies suggest that primary esophageal repair should be performed for perforations, and some authors suggest that there are benefits from thoracoscopic surgery in cases that are diagnosed early. METHODS From December 2004 to May 2010, 15 patients with Boerhaaves syndrome presented to our department; the medical records were reviewed retrospectively for preoperative signs and symptoms, interval between perforation and surgery, surgical methods, and outcomes of treatment. The patients were divided into two groups according to the surgical approach (thoracoscopy versus thoracotomy) to evaluate the outcomes of thoracoscopic surgery in patients with Boerhaaves syndrome. RESULTS All patients were men, with a mean age of 53.1 years, and all underwent primary esophageal repair. Seven patients underwent a thoracoscopic approach (group A) and eight patients had a thoracotomy (group B). The mean interval between perforation and surgery was 43.5 hours (group A) and 40.2 hours (group B) (p=0.487). The mean operative time was 3.7 hours (group A) and 5.3 hours (group B) (p=0.005). Postoperative leaks were confirmed by esophagography in one patient in group A and in two patients in group B. There was no mortality in group A and one death postoperatively in group B. CONCLUSIONS The results of this study suggest that thoracoscopic esophageal repair may be a good surgical alternative in patients with Boerhaaves syndrome who have a relatively stable vital sign or mild inflammation, regardless of the time interval between perforation and surgery.

The Feasibility of Extracorporeal Membrane Oxygenation in the Variant Airway Problems

INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is widely used to treat respiratory distress during cardiac or respiratory arrest; moreover, its use is being extended to a wide variety of clinical fields. In this study we assess the utility of ECMO in the management of airway obstruction. PATIENTS AND METHODS 15 patients underwent ECMO for airway obstruction. We retrospectively analyzed and evaluated the feasibility of ECMO in the treatment of airway problems. RESULTS Seven patients received ECMO to facilitate respiration and promote stability during trachea surgery. In six cases ECMO ceased immediately following the operation; in the remaining case ECMO cessation was delayed due to post-operative ARDS. In three cases emergency ECMO was used in response to respiratory arrest; two patients died. In five cases ECMO was emergently inserted to prevent death, following airway blockade by massive hemoptysis. One patient was not discharged from the intensive care unit. Another patient was transferred to a general ward but died from other causes. CONCLUSION ECMO is useful during anesthesia in patients at high risk of airway blockade, for example due to endobronchial bleeding, and during complex thoracic surgery. ECMO confers a safer environment during airway surgery, and its complication rate is acceptable.

The Effect of Thoracoscopic Pleurodesis in Primary Spontaneous Pneumothorax: Apical Parietal Pleurectomy versus Pleural Abrasion

Background The standard operative treatment of primary spontaneous pneumothorax (PSP) is thoracoscopic wedge resection, but necessity of pleurodesis still remains controversial. Nevertheless, pleural procedure after wedge resection such as pleurodesis has been performed in some patients who need an extremely low recurrence rate. Materials and Methods From January 2000 to July 2010, 207 patients who had undergone thoracoscopic wedge resection and pleurodesis were enrolled in this study. All patients were divided into two groups according to the methods of pleurodesis; apical parietal pleurectomy (group A) and pleural abrasion (group B). The recurrence after surgery had been checked by reviewing medical record through follow-up in ambulatory care clinic or calling to the patients, directly until January 2011. Results Of the 207 patients, the recurrence rate of group A and B was 9.1% and 12.8%, respectively and there was a significant difference (p=0.01, Coxs proportional hazard model). There was no significant difference in age, gender, smoking status, and body mass index between two groups. Conclusion This study suggests that the risk of recurrence after surgery in PSP is significantly low in patients who underwent thoracoscopic wedge resection with parietal pleurectomy than pleural abrasion.

Chemical Pleurodesis Using Mistletoe Extraction (ABNOVAviscum® Injection) for Malignant Pleural Effusion

PURPOSE Malignant pleural effusion (MPE) is common in patients with advanced cancer. Chemical pleurodesis can be considered for MPE that do not respond to chemotherapy, radiotherapy, or therapeutic thoracentesis. However, it is not yet clear which agent is more effective and safer in chemical pleurodesis. METHODS This study was designed as a single arm, multicenter, and open-label phase III clinical trial to evaluate efficacy and safety of chemical pleurodesis using mistletoe extraction (ABNOVAviscum(®) Injection). References of other agents in chemical pleurodesis were investigated to compare efficacy and safety. Efficacy was evaluated by followed up chest X-ray and changes of clinical symptoms and Karnofsky performance scale. Safety was evaluated by serious adverse event (SAE) and changes of laboratory findings. A follow-up period was 4 weeks after last pleurodesis. RESULTS Of 62 patients, 49 (79.0%) had complete response, 11 (17.7%) had partial response, and two had no response. Mean response rate was significantly different in this study comparing with reference response rate which was 64% (p <0.0001). There were two SAEs, but all were recovered without sequelas. CONCLUSION The results of this study suggest that mistletoe extraction (ABNOVAviscum(®) Injection) could be an effective and safe agent of chemical pleurodesis in patients with MPE.

Discriminating between Terminal- and Non-Terminal Respiratory Unit-Type Lung Adenocarcinoma Based on MicroRNA Profiles

Lung adenocarcinomas can be classified into terminal respiratory unit (TRU) and non-TRU types. We previously reported that non-TRU-type adenocarcinoma has unique clinical and morphological features as compared to the TRU type. Here we investigated whether micro (mi)RNA expression profiles can be used to distinguish between these two subtypes of lung adenocarcinoma. The expression of 1205 human and 144 human viral miRNAs was analyzed in TRU- and non-TRU-type lung adenocarcinoma samples (n = 4 each) by microarray. Results were validated by quantitative real-time (qRT-)PCR and in situ hybridization. A comparison of miRNA profiles revealed 29 miRNAs that were differentially expressed between TRU- and non-TRU adenocarcinoma types. Specifically, hsa-miR-494 and ebv-miR-BART19 were up regulated by > 5-fold, whereas hsa-miR-551b was down regulated by > 5-fold in the non-TRU relative to the TRU type. The miRNA signature was confirmed by qRT-PCR analysis using an independent set of paired adenocarcinoma (non-TRU-type, n = 21 and TRU-type, n = 12) and normal tissue samples. Non-TRU samples showed increased expression of miR-494 (p = 0.033) and ebv-miR-BART19 (p = 0.001) as compared to TRU-type samples. Both miRNAs were weakly expressed in the TRU type but strongly expressed in the non-TRU type. Neither subtype showed miR-551b expression. TRU- and non-TRU-type adenocarcinomas have distinct miRNA expression profiles, suggesting that tumorigenesis in lung adenocarcinoma occur via different pathways.

Does Surgical Repair Still have a Role for Iatrogenic Tracheobronchial Rupture? Clinical Analysis of a Thoracic Surgeon's Opinion.

PURPOSE The choice of surgical repair or conservative treatment for iatrogenic tracheobronchial rupture (ITBR) remains controversial. However, thoracic surgeons consider that surgical repair is an important treatment modality. The purpose of this study was to evaluate the clinical results from the perspective of the surgery-preferred group. METHODS We treated 11 patients (8 women and 3 men; age: 52.6 ± 22.9 years) with ITBR from January 2011 to January 2016. A posterolateral thoracotomy or a trans-tracheal approach was performed according to the mechanism of injury. RESULTS Nine patients underwent surgery, and all patients received primary repair. Five patients received a right posterolateral thoracotomy, whereas one patient received a left posterolateral thoracotomy. No mortality or morbidity related to the surgery was observed. The mechanical ventilation time was 65.9 ± 99.2 hours. The intensive care unit duration was 19.7 ± 33.3 days. Two patients received conservative treatment, and all patients died of another disease that was not related to the conservative treatment. CONCLUSION Our mortality or morbidity due to surgery was not higher than world literature results of conservative treatment. We thought surgery is the primary treatment choice for ITBR in the absence of a good indication for conservative treatment.

Pulmonary mass diagnosed as extrauterine epithelioid trophoblastic tumor.

Pulmonary extrauterine epithelioid trophoblastic tumors (ETTs) are extremely rare. A 26-year-old nonsmoking woman with a history of a suspected subclinical miscarriage presented with a large mass in the right lower lobe that was confirmed to be a pulmonary extrauterine ETT using immunohistochemical stains. When a nonsmoking fertile woman presents with a pulmonary mass and an elevated serum β-human chorionic gonadotrophin in the absence of gynecologic disease, pulmonary extrauterine ETT should be considered.

Single-Incision Video-Assisted Thoracoscopic Surgery for Benign Mediastinal Diseases: Experiences in Single Institution

With advancement of the technique of video-assisted thoracic surgery (VATS), some surgeons have made great efforts to reduce the number of incisions in the conventional three- or four-port approach. Several studies on cases treated by single-incision VATS and their short-term outcomes were reported. Here, we present our experience with single-incision VATS for the treatment of benign mediastinal diseases.

Outcomes of Extracorporeal Life Support During Surgery for the Critical Airway Stenosis

Anesthetic management of critical airway stenosis is often very challenging. Extracorporeal membrane oxygenation (ECMO) may provide adequate respiratory support when conventional approaches fail. We report our experience of ECMO support for critical airway surgery. Between April 2012 and March 2015, nine patients underwent ECMO-supported airway operation. The reason for surgery was tracheal stenosis in nine patients, and tracheomalacia, tracheal tumor, and external tracheal compression by mediastinal mass in one patient each. Resection and end-to-end anastomosis was performed in four patients; the remainder underwent diverse procedures, including tracheoplasty, tracheal ballooning, tracheostomy, and debulking of mediastinal mass. Extracorporeal membrane oxygenation support was sufficient for gas exchange during surgery and six patients were successfully weaned off intraoperatively. The median time on ECMO was 2.42 hours (range: 14.43−216 hours). No ECMO-related complications occurred. The median intensive care unit stay, median hospital stay, and mean follow-up period were 2 days (range: 1−61 days), 33 days (range: 9−303 days), and 17.1 ± 10.8 months, respectively. The rate of freedom from reintervention was 71.4%; the mean survival rates over 1 and 2 years were 76.2% and 63.5%, respectively. Our experience indicates that ECMO is a feasible and safe method for critical airway surgery.

Surgical Outcomes of Pneumatic Compression Using Carbon Dioxide Gas in Thoracoscopic Diaphragmatic Plication.

Background Surgical correction needs to be considered when diaphragm eventration leads to impaired ventilation and respiratory muscle fatigue. Plication to sufficiently tense the diaphragm by VATS is not as easy to achieve as plication by open surgery. We used pneumatic compression with carbon dioxide (CO2) gas in thoracoscopic diaphragmatic plication and evaluated feasibility and efficacy. Methods Eleven patients underwent thoracoscopic diaphragmatic plication between January 2008 and December 2013 in Pusan National University Hospital. Medical records were retrospectively reviewed, and compared between the group using CO2 gas and group without using CO2 gas, for operative time, plication technique, duration of hospital stay, postoperative chest tube drainage, pulmonary spirometry, dyspnea score pre- and postoperation, and postoperative recurrence. Results The improvement of forced expiratory volume at 1 second in the group using CO2 gas and the group not using CO2 gas was 22.46±11.27 and 21.08±5.39 (p=0.84). The improvement of forced vital capacity 3 months after surgery was 16.74±10.18 (with CO2) and 15.6±0.89 (without CO2) (p=0.03). During follow-up (17±17 months), there was no dehiscence in plication site and relapse. No complications or hospital mortalities occurred. Conclusion Thoracoscopic plication under single lung ventilation using CO2 insufflation could be an effective, safe option to flatten the diaphragm.