Sang Gi Oh

Learning curves of minimally invasive esophageal cancer surgery

BACKGROUND Minimally invasive esophageal cancer surgery (MIES) has been performed at some experienced health centers. MIES has shown to be feasible and safe in esophageal cancer surgery. However, there are a few reports concerning the learning curve of MIES. METHODS From 2004 to 2007, MIES was performed in 28 patients by a single surgeon. This amount includes total MIES that contained thoracoscopic esophagectomy, laparoscopic gastric preparation, cervical anastomosis and hybrid MIES that contained only one scope surgery. Surgical outcomes and clinical factors in the first 14 patients (group A) and the other 14 patients (group B) were compared. RESULTS There were no differences in clinical factors between the two groups. Total MIES was completed in 14 patients, while 13 patients underwent hybrid MIES. There were 6 cases of emergent conversion to open procedures; one case was a thoracotomy and 5 cases were a laparotomy. Chest, abdominal, and total operation time were shorter in group B (p<0.05). The amount of red cell transfusions and intensive care unit stay times were less in the total MIES group (p<0.05). There was one hospital mortality due to acute respiratory distress syndrome. Postoperative complication rate was 43%. CONCLUSIONS As cases increase, surgical outcomes have improved. We think that this report showed a substantial learning curve for a complex surgery such as MIES.

Traumatic rupture of the coronary sinus following blunt chest trauma: a case report

Cardiac rupture is rare but potentially life-threatening complication after chest trauma. We present the case of a 57-year-old male who developed cardiac arrest because of extensive pericardial tamponade after a falling injury. We decided to perform an exploratory sternotomy in the operating room (OR). The patient was transported to the OR on extracorporeal membrane oxygenation (ECMO) support. We found a rupture of the coronary sinus after evacuation of an extensive hematoma in the pericardium and primarily repaired the injured site. After 2 days, the patient died due to refractory cardiogenic shock. To our knowledge, this is the first reported case of rupture of the coronary sinus after blunt chest trauma.

Mediastinal thoracic duct cyst adjacent to left pericardium

Fig. 1. A chest computed tomography showed a 5.5 4.5 cm sized, homogeneous, non-enhancing cystic mass with a well-defined border, situated beside the left pericardium superior to the diaphragm (A, B). Thoracoscopic view of the cyst, located at the left cardiophrenic angle which was adherent to the diaphragm and pericardium anterior to the phrenic nerve. The wall was smooth and somewhat transparent (C). The retrieved cyst filled with saline (D) (P: pericardium, L: collapsed lung, and Arrow: phrenic nerve).

Subsequently occurring bilateral iliopsoas hematoma: a case report

BackgroundSpontaneous bilateral iliopsoas hematomas is a rare complication after anticoagulant therapy. Furthermore, the onset of bilateral iliopsoas hematoma is unknown because the causes are unclear.Case PresentationA 65-year-old man on anticoagulant therapy after mechanical aortic valve replacement was admitted after presenting with severe pain in the left flank and abdomen. Abdominal CT revealed a large left-sided iliopsoas hematoma with extravasation. Fresh frozen plasma was transfused due to prolonged prothrombin time. Transarterial embolization was successfully performed. During the hospital stay, follow-up abdominal CT was performed and a small right-sided iliopsoas hematoma was detected. This was closely observed and an intervention was not performed, as the patient was asymptomatic. The final CT prior to discharge revealed a reduction in size of each hematoma.ConclusionsSpontaneous bilateral iliopsoas hematoma can be developed subsequently. Patients with unilateral iliopsoas hematoma should be closely monitored for development of bilateral iliopsoas hematoma.

Predictive Value of Procalcitonin for Infection and Survival in Adult Cardiogenic Shock Patients Treated with Extracorporeal Membrane Oxygenation

Procalcitonin (PCT) is a predictive marker for the occurrence of bacterial infection and the decision to terminate antibiotic treatment in critically ill patients. An unusual increase in PCT, regardless of infection, has been observed during extracorporeal membrane oxygenation (ECMO) support. We evaluated trends and the predictive value of PCT levels in adult cardiogenic shock during treatment with ECMO. We reviewed the clinical records of 38 adult cardiogenic shock patients undergoing veno-arterial ECMO support between January 2014 and December 2016. The exclusion criteria were age <18 years, pre-ECMO infection, and less than 48 hours of support. The mean patient age was 56.7±14.7 years and 12 (31.6%) patients were female. The mean duration of ECMO support was 9.0±7.6 days. The rates of successful ECMO weaning and survival to discharge were 55.3% (n=21) and 52.6% (n=20), respectively. There were 17 nosocomial infections in 16 (42.1%) patients. Peak PCT levels (mean 25.6±9.4 ng/mL) were reached within 48 hours after initiation of ECMO support and decreased to ≤5 ng/mL within one week. The change in PCT levels was not useful in predicting the occurrence of new nosocomial infections during the ECMO run. However, a PCT level >10 ng/mL during the first week of ECMO support was significantly associated with mortality (p<0.01). The change in PCT level was not useful in predicting new infection during ECMO support. However, higher PCT levels within the first week of the ECMO run are associated with significantly higher mortality.

Nosocomial Infection in Adult Patients Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation

Data on the frequency of nosocomial infections during extracorporeal membrane oxygenation (ECMO) in adult populations remain scarce. We investigated the risk factors for nosocomial infections in adult patients undergoing venoarterial ECMO (VA-ECMO) support. From January 2011 to December 2015, a total of 259 patients underwent ECMO. Of these, patients aged 17 years or less and patients undergoing ECMO for less than 48 hours were excluded. Of these, 61 patients diagnosed with cardiogenic shock were evaluated. Mean patient age was 60.6 ± 14.3 years and 21 (34.4%) patients were female. The mean preoperative Sequential Organ Failure Assessment (SOFA) score was 8.6 ± 2.2. The mean duration of ECMO support was 6.8 ± 7.4 days. The rates of successful ECMO weaning and survival to discharge were 44.3% and 31.1%, respectively. There were 18 nosocomial infections in 14 (23.0%) patients. These included respiratory tract infections in 9 cases and bloodstream infections in a further 9. In multivariate analysis, independent predictors of infection during ECMO were the preoperative creatinine level (hazard ratio [HR], 2.176; 95% confidence interval [CI], 1.065–4.447; P = 0.033) and the duration of ECMO support (HR, 1.400; 95% CI, 1.081–1.815; P = 0.011). A higher preoperative creatinine level and an extended duration of ECMO support are risk factors for infection. Therefore, to avoid the development of nosocomial infections, strategies to shorten the length of ECMO support should be applied whenever possible.

Surgery for hemoptysis in patients with benign lung disease

Background Hemoptysis can be a life-threatening condition that requires urgent treatment. Surgery still plays an important role in managing this critical situation, although previous reports have reported high postoperative morbidity and mortality rates. We report our experience with surgical resection for hemoptysis caused by benign lung diseases. Methods We reviewed the retrospectively collected data from 94 patients undergoing pulmonary resection for various benign lung diseases with hemoptysis at a single institution from 2010 to 2016. Baseline characteristics, surgical factors, and postoperative outcomes (morbidity and mortality rates) were analyzed. Results The ratio of male to female patients was 1:1, and the mean age was 58.2±11.1 (range, 29-79) years. The etiology of hemoptysis included aspergilloma in 58 patients (61.7%), bronchiectasis in 10, tuberculosis in 7, necrotizing bronchiolitis in 6, and other inflammatory disease in 13. A total of 21 patients (22.3%) underwent emergency operation, and 73 (77.7%) had an elective operation. Pulmonary resection was performed by thoracotomy (n=53, 56.4%) and video-assisted thoracoscopic surgery (VATS) (n=41, 43.6%). Sublobar resection (n=50, 53.2%, segmentectomy in 19 and wedge resection in 31) was performed more often than lobectomy (n=35, 37.2%). Pneumonectomy was performed in 7 patients, and bilobectomy was performed in 2. Postoperative morbidity occurred in 23 patients (24.5%), with prolonged air leak being the most frequent complication (n=14, 14.9%). The in-hospital mortality rate was 3.2% (n=3). Complications were less frequent in patients undergoing an elective operation, VATS, and sublobar resection. Multivariate analysis showed that patients treated with VATS had a decreased risk of postoperative complications (odds ratio, 12.8; 95% confidence interval, 1.29-127.9; P=0.03). Conclusions Surgical resection for hemoptysis in patients with benign lung diseases is the mainstay of effective treatment with acceptable morbidity and mortality rates. If applicable, we recommend elective (planned) sublobar resection using VATS in order to improve postoperative outcomes.

Supraclavicular transposition of aberrant left vertebral artery for hybrid treatment of aortic arch aneurysm: a case report

BackgroundVertebral artery variations are common in thoracic aortic patients. If patients have the aberrant left vertebral artery, the more difficult to determine the treatment modality.Case presentationWe report the case of a 63-year-old man with an aberrant left vertebral artery originating from an aneurysmal aortic arch. The patient underwent a successful hybrid thoracic endovascular aortic repair after aortic arch debranching and transposition of the aberrant left vertebral artery to the left common carotid artery through a supraclavicular incision without sternotomy.ConclusionsThe aberrant left vertebral artery originating from the aortic arch can be safely transposed to the left common carotid artery through a supraclavicular approach.

Aorta-right atrial tunnel in a patient with multivalvular endocarditis.

Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea Correspondence Sang Gi Oh MD, Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, 42, Jebong-ro, Dong-gu, Gwangju, 501-757, Republic of Korea. Email: drosg@hanmail.net

Coronary Sinus Ostial Atresia Presenting as Infective Endocarditis in a Previously Healthy Young Woman

Coronary sinus ostial atresia is a rare disease. Most patients are usually asymptomatic and diagnosed incidentally during surgery or at autopsy. We report a case of coronary sinus ostial atresia with unroofed coronary sinus syndrome in a previously healthy woman who presented with infective endocarditis.