Won Min Jo

Minimally invasive repair of pectus excavatum: A novel morphology-tailored, patient-specific approach

OBJECTIVE Minimally invasive repair of pectus excavatum, introduced by Nuss in 1998, has undergone a serious learning curve because of a lack of understanding on morphologies and repair techniques. To summarize the current status of minimally invasive repair of pectus excavatum, we reviewed and appraised our 10-year experience with a novel approach, a morphology-tailored technique, including diverse bar shaping, bar fixation, and techniques for adults. METHODS We analyzed the data of 1170 consecutive patients with pectus excavatum who underwent minimally invasive repair between August 1999 and September 2008. All pectus repairs were performed by the primary author (H.J.P.) with our modified technique. RESULTS The mean age was 10.3 years (range, 16 months to 51 years). There were 331 adult patients (>15 years) (28.3%). A total of 576 patients (49.2%) had bar removal after a mean of 2.5 years (range, 10 days to 7 years). The asymmetry index change (1.10-1.02, P < .001) demonstrated post-repair symmetry. Complication rates decreased through the 3 time periods (1999-2002 [n = 335]; 2003-2005 [n = 441]; 2006-2008 [n = 394]) as follows: pneumothorax rate (7.5% vs 4.3% vs 0.8%; P < .001) and bar displacement rate (3.8% vs 2.3% vs 0.5%; P = .002). Reoperation rate also decreased (4.8% vs 2.5% vs 0.8%; P = .002). Satisfaction outcomes were excellent in 92.7%, good in 5.9%, and fair in 1.4% of patients. After bar removal, 3 patients (0.6%) had minor recurrences. CONCLUSION Minimally invasive repair of pectus excavatum based on a novel morphology-tailored, patient-specific approach is effective for quality repair of the full spectrum of pectus excavatum, including asymmetry and adult patients. Continuous technical refinements have significantly decreased the complication rates and postoperative morbidity.

Needlescopic Lung Biopsy for Interstitial Lung Disease and Indeterminate Pulmonary Nodules: A Report on 65 Cases

BACKGROUND We evaluated the feasibility and accuracy of a needlescopic procedure for lung biopsies in patients with interstitial lung disease or indeterminate pulmonary nodules. METHODS Sixty-five patients (36 women; mean age, 51.3 +/- 15.6; range, 13 to 76 years) underwent a needlescopic procedure to obtain lung biopsy specimens. Forty had indeterminate pulmonary nodules, and 25 had interstitial lung disease. A 2-mm needlescope and a 2-mm MiniSite Endo Grasp (Covidien, Norwalk, CT) were inserted at the sixth intercostal space along the middle and the posterior axillary line, respectively. Biopsy specimens were obtained using endostaplers. RESULTS The average number of biopsy specimens was 1.7 +/- 0.6 (range, 1 to 4). For 9 patients, a frozen specimen was sent twice to pathology. Complete resection was continued after intraoperative pathology confirmation in 13 patients (lobectomy, 7; segmentectomy, 3; mass removal, 1; metastasectomy, 2). The volume of lung tissue was 8.7 +/- 11.8 cm3 (range, 0.15 to 55.44 cm3). The operation time was 58.7 +/- 37.5 minutes (range, 15 to 160 minutes). The final pathologic results were confirmed in all patients. No thoracoscopic procedure was converted to an open thoracotomy. Three patients (4.3%) had prolonged air leakage (> 5 days), and the chest tube remained in the pleural space for 2.3 +/- 2.4 days (range, 1 to 8 days). CONCLUSIONS Needlescopic operation for lung biopsies in patients with interstitial lung disease and indeterminate pulmonary nodules is a minimally invasive procedure that is safe and effective for obtaining a diagnosis in selected patients.

Gap junction remodelling by chronic pressure overload is related to the increased susceptibility to atrial fibrillation in rat heart

AIMS Left atrial (LA) fibrosis caused by various pathological stimuli is a common finding. However, the difference of atrial remodelling via haemodynamic change in diverse cardiomyopathy has not been elucidated. METHODS AND RESULTS Male Sprague-Dawley rats (6-8 weeks, n = 180) were randomly assigned to three groups and corresponding sham control groups: (i) ischaemic cardiomyopathy, (ii) left ventricular hypertrophy (LVH), and (iii) dilated cardiomyopathy. At 12 weeks after operation, atrial fibrillation (AF) inducibility and duration were assessed by in vivo burst transoesophageal pacing. Using the Langendorff apparatus, left ventricular (LV) function and pressure were measured. The expression of connexin-43 (Cx43) and alpha-smooth muscle actin (α-SMA) in atrial tissues was assessed by quantitative real-time polymerase chain reaction and immunohistochemical staining. Fibrosis was analysed by Massons trichrome staining. Compared with controls, the LA weight/heart weight ratio was increased in the LVH group alone, and was significantly correlated with AF duration (P < 0.001, R = 0.388). Atrial fibrillation inducibility and duration were higher and longer only in the LVH group (P = 0.002, 0.079, respectively), and isolated LV diastolic dysfunction and elevated LV pressure were observed. Although α-SMA expression and fibrosis were increased in all three cardiomyopathy models, down-regulation of Cx43 expression in the LA was observed in the LVH group alone. CONCLUSION Chronic pressure overload in the absence of LV systolic dysfunction resulted in LA hypertrophy and increased susceptibility to AF, which might be related to conduction abnormality via decreased expression and lateral distribution of Cx43 as well as interstitial fibrosis.

Myocardial Protective Effect of Tezosentan, an Endothelin Receptor Antagonist, for Ischemia-Reperfusion Injury in Experimental Heart Failure Models

The myocardial protective effects of endothelin antagonist in ischemic cardiomyopathy (ICMP), doxorubicin-induced cardiomyopathy (DOX) and pressure-overload hypertrophy by transverse aortic constriction (TAC) models have been predicted to be different. The objective of this experiment, therefore, is to evaluate the myocardial protective effect of tezosentan, an endothelin receptor antagonist, in various experimental heart failure models. Sprague-Dawley rats (6-8 weeks old, 200-300 g) were randomized to three experimental groups (n=30 each): ICMP; DOX; and TAC group. Each of these groups was randomly assigned further to the following subgroups (n=10 each): sham-operated ischemia-reperfusion subgroup (SHAM); tezosentan treated ischemia-reperfusion subgroup (Tezo); and tezosentan non-treated ischemia-reperfusion subgroup (N-Tezo). Total circulatory arrest was induced for 1 hr, followed by 2 hr of reperfusion. The left ventricular developed pressure, peak positive and negative first derivatives, and coronary blood flow were significantly different (P<0.05) among the SHAM, Tezo, and N-Tezo subgroups of the ICMP group at 30 min of reperfusion, but there were no statistically significant differences among the subgroups of the DOX and TAC groups. In conclusion, tezosentan, an endothelin receptor antagonist, showed myocardial protection effects only on the ischemic cardiomyopathy rat model, but not in the non-ischemic heart failure rat models.

Thrombosis in Behçet's disease: a Behçet's disease patient with complete thrombotic obstruction of IVC and both iliac veins and decreased protein S activity.

Behçet’s disease represents a multisystemic inflammatory disease characterized by recurrent oral ulcers, genital ulcers, and uveitis. Although vascular attack and thrombosis are not major complications in Behçet’s disease, they can still pose risks that must not be overlooked. In this paper, we reported that a 25-year-old female Behçet’s disease patient with complete thrombotic obstruction of the inferior vena cava that was successfully treated by aspiration thrombectomy and balloon angioplasty. The procedure produced marked symptomatic improvement. Currently, data about the treatment and the prophylaxis of thrombotic events in Behçet’s disease are lacking. In this case report, we hope to discuss the future direction of such studies, how we understand the mechanism of Behçet’s disease hypercoagulability, and which treatments can improve thrombotic tendencies in Behçet’s disease.

Comparison of clinical outcomes of pharmacomechanical thrombectomy in iliac vein thrombosis with and without may-thurner syndrome.

BACKGROUND May-Thurner syndrome (MTS) has a different etiology from that of general deep vein thrombosis (DVT). However, few clinical comparisons of MTS-induced and non-MTS-induced DVT have been reported. The aim of this study was to analyze the clinical results of pharmaco-mechanical thrombectomy (PMT) in DVT with and without MTS. METHODS Forty-seven iliac vein thrombosis patients treated with PMT between January 2008 and December 2013 were enrolled. 25 patients had DVT with MTS and 22 patients had iliac vein DVT without MTS. We retrospectively reviewed medical records and analyzed mid-term patencies and post-thrombotic syndrome (PTS) occurrence by Villalta Score. RESULTS The median follow-up period was 48.4 (36~92) months. A venous stent was inserted in the iliac vein in all MTS patients. One-/two-/three-year primary patencies in the non-MTS group were 77.3% (N.=17) for all three years in the non-MTS group and were 96.0% (N.=24), 83.1% (N.=22), and 83.1% (N.=22) in the MTS group for years 1/2/3, respectively. One-/two-/three-year secondary patencies were 90.9% (N.=20) for all three years in the non-MTS group and were 96.0% (N.=24), 91.4% (N.=23), and 91.4% (N.=23) in the MTS group, respectively. One-, two-, and three-year Villalta Scores were 4.3, 3.9, and 3.4, respectively, in the non-MTS group, and 3.8, 3.7, and 4.0, respectively, in the MTS group. Primary and secondary patency and Villalta Score were not significantly different between the MTS and non-MTS groups. CONCLUSIONS Although MTS and DVT have different etiologies, clinical results for both diseases using PMT were not significantly different. Therefore, PMT can be offered as an acceptable initial therapy in DVT patients with and without MTS.

Effects of a proteasome inhibitor on cardiomyocytes in a pressure-overload hypertrophy rat model: An animal study

Background The ubiquitin-proteasome system (UPS) is an important pathway of proteolysis in pathologic hypertrophic cardiomyocytes. We hypothesize that MG132, a proteasome inhibitor, might prevent hypertrophic cardiomyopathy (CMP) by blocking the UPS. Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and androgen receptor (AR) have been reported to be mediators of CMP and heart failure. This study drew upon pathophysiologic studies and the analysis of NF-κB and AR to assess the cardioprotective effects of MG132 in a left ventricular hypertrophy (LVH) rat model. Methods We constructed a transverse aortic constriction (TAC)-induced LVH rat model with 3 groups: sham (TAC-sham, n=10), control (TAC-cont, n=10), and MG132 administration (TAC-MG132, n=10). MG-132 (0.1 mg/kg) was injected for 4 weeks in the TAC-MG132 group. Pathophysiologic evaluations were performed and the expression of AR and NF-κB was measured in the left ventricle. Results Fibrosis was prevalent in the pathologic examination of the TAC-cont model, and it was reduced in the TAC-MG132 group, although not significantly. Less expression of AR, but not NF-κB, was found in the TAC-MG132 group than in the TAC-cont group (p<0.05). Conclusion MG-132 was found to suppress AR in the TAC-CMP model by blocking the UPS, which reduced fibrosis. However, NF-κB expression levels were not related to UPS function.

Video-assisted thoracoscopic surgery for intrathoracic first rib resection in thoracic outlet syndrome

BACKGROUND First rib resection is a surgical treatment for decompressing the neurovascular structures in thoracic outlet syndrome (TOS). Historically, extrathoracic approaches have used a posterior, supraclavicular, or transaxillary incision to remove the first rib. In this report, we demonstrate video-assisted thoracoscopic surgery for intrathoracic first rib resection (VATS-IFRR). METHODS Between 2009 and 2014, eight patients underwent VATS-IFRR for TOS. Surgery was performed through two 5-mm ports and one 10-mm port. Endoscopic graspers, a hook-type electrocautery probe, a long peapod intervertebral disc rongeur, and Kerrison punches were used. The types of disease, operative times, chest tube indwelling days, lengths of hospital stay after operation, perioperative complications, postoperative pain scale ratings, and postoperative symptom recurrence rates at provocation tests were reviewed. The surgical outcomes were compared to published outcomes of extrathoracic approaches and other VATS approaches. RESULTS The eight patients (3 right ribs, 5 left ribs) exhibited neurogenic (1 patient), combined type (2 patients), arterial (4 patients), and venous type (1 patient) TOS. The mean operative time was 190 (range 155-310) minutes. No mortalities or major complications occurred. The mean chest tube indwelling duration was 6 (range 3-10) days, and the mean postoperative hospital stay was 9 (range 4-21) days. The mean immediate postoperative pain numeric rating scale (NRS) score was 2.7/10 (range 2-4). No recurrence was observed during follow-up (median 25.5 months, range 10-64 months) in any patient. CONCLUSIONS VATS-IFRR was safe and had several advantages. Thus, VATS-IFRR is a minimally invasive surgical option suitable for treating selective cases of TOS.

The Role of Pharmacomechanical Endovascular Intervention for Iliofemoral Vein Thrombosis Compared to Conventional Anticoagulation Therapy

Although anticoagulation therapy is the primary treatment for deep vein thrombosis (DVT), it has not been associated with the rapid recanalization of the venous occlusion. Moreover, it is associated with long-term disability due to post-thrombotic syndrome (PTS). In contrast, pharmacomechanical endovascular intervention (PMI) results in more rapid clinical improvement in DVT patients, but there are few reports on its long-term outcomes. This retrospective study evaluated the clinical effectiveness of PMI compared to conventional anticoagulation therapy (ACA) for acute and subacute iliofemoral DVT. We reviewed the medical records of 102 patients with iliofemoral DVT. A total of 46 patients for ACA and 56 patients for PMI were enrolled. We analyzed the clinical differences between the PMI and ACA groups by comparing the clinical signs, residual DVT free-rate, and PTS-free rate. There were no statistically significant differences in the demographic characteristics and risk factors except age between the groups (age: ACA, 52.0 ± 18.0 years; PMI, 59.0 ± 17.0 years; P = 0.035). The 1-, 3-, and 5-year residual DVT-free rate (ACA = 84.7%, 71.6%, and 46.0%; PMI = 82.1%, 76.8%, and 76.8%, respectively; P = 0.235) was not significantly different. However, the 1-, 3-, and 5-year PTS-free rate was significantly different (ACA = 93.5%, 74.0%, and 55.7%; PMI = 92.9%, 90.0%, and 90.0%, respectively; P = 0.019). There was no significant difference in the rate of other complications. PMI showed a lower incidence of PTS during the follow-up period. Therefore, PMI should be considered as an effective therapeutic modality for patients with iliofemoral DVT.