Young Du Kim

Clinical experience of spontaneous pneumomediastinum: diagnosis and treatment

BACKGROUND Spontaneous pneumomediastinum (SPM) is a benign disease with a variety degree of severity but definite treatment modality is not clearly identified with its rarity. The purpose of this study was to review our experience and discuss the management of SPM according to the severity of disease. METHODS From March 1996 to December 2012, total 64 patients were enrolled and classified as mild, moderate and severe groups and subsequent clinical courses were analyzed retrospectively. RESULTS Fifty-one were males and 13 were females (M:F =3.9:1) with a mean age of 18 years old (range: 10-30 years old). Thirty-six patients were in mild, 22 in moderate and 6 in severe group. Chief complaints were chest pain (50 cases; 78.1%), neck pain (35 cases; 54.7%), dyspnea (18 cases; 28.1%), odynophagia (9 cases; 14.1%) and precipitating factors were coughing in 12 cases, feeding problems in 9 cases, and vomiting in 7 cases; however, 34 patients (53.1%) had no precipitating signs. All patients received oxygen therapy (100%), prophylactic antibiotics in 57 patients (89.1%), and pain medications in 47 patients (73.4%). The mean hospital stay was 4.6 days (range: 1-10 days). There was an increased linear trend according to time to visit (P=0.023) but clinical course demonstrated no significant trend between groups. CONCLUSIONS These data demonstrated that there was no difference in symptom, clinical course and SPM was adequately treated with conservative management regardless of the degree of severity of SPM.

New protocol for a reversal operation in endoscopic thoracic sympathetic clamping: pulling back the suture sling linked to the clip under local anesthesia.

Endoscopic thoracic sympathetic clamping (ETC) has widely been used for treating the patients with primary hyperhidrosis, as it offers the potential of reversal operation (unclipping) under general anesthesia (GA) when severe reflex sweating would occur. However, we modified ETC to unclip under local anesthesia. From March 2002 to January 2005, we performed ETC in 87 patients with primary hyperhidrosis. From September 2002 on, the suture sling which was made with a 3-0 propylphylene suture was additionally placed between the endoclip and the subcutaneous tissue of the thoracoport. When unclipping was needed, the endoclip was removed by being pulled back under portable fluoroscopy. Four of 53 patients (7.5%) who underwent ETC alone underwent unclipping under GA. By contrast, unclipping was successfully performed under local anesthesia in 5 of 34 patients (14.7%) who underwent the modified ETC. ETC will be more effective operation if it is modified concomitantly with the suture sling; otherwise the reversal operation will need GA for the unclipping.

Intractable hiccup accompanying pleural effusion: reversible clipping of an intrathoracic phrenic nerve.

Hiccup is usually a self-limiting condition, and can be treated with medications and physical maneuvers. However, hiccup episodes continuing for days or weeks can be incapacitating, and disturb work, sleep, and eating. Therefore, timely therapeutic intervention is needed to achieve early resolution of this treatable condition. We report on a successful phrenic nerve block for intractable hiccups, which consisted of thoracoscopic nerve clipping under general anesthesia and reversal under local anesthesia. This method has the advantage of assured diaphragmatic functional recovery while controlling intractable hiccups.

Integration of Gene-Expression Profiles and Pathway Analysis in Ascending Thoracic Aortic Aneurysms

BACKGROUND Despite the increasing incidence of ascending thoracic aortic aneurysms, their pathogenesis and molecular mechanisms remain unknown. The aim of this study was to identify the biological pathways of genes that are expressed differentially in ascending aortic aneurysms. METHODS Aneurysm wall tissues were obtained from thoracic aortic aneurysms during their repair and normal thoracic aortas from organ transplant patients. The differential expression of genes was analyzed by NimbleGen microarrays. The biological pathways and processes were identified using Kyoto Encyclopedia of Genes and Genome pathway analysis and gene ontology analysis. RESULTS Among 45,034 genes, 95 were differentially expressed (>two-fold change compared with control). A total of 76 genes were up-regulated and 19 genes were down-regulated in patients with ascending thoracic aneurysm. Analysis of the Kyoto Encyclopedia of Genes and Genomes pathways revealed 26 biologically functional pathways in the following categories: focal adhesion, cell junctions, peroxisome proliferator-activated receptor signaling pathway, extracellular matrix-receptor interaction, T-cell-receptor signaling pathway, B-cell-receptor signaling pathway, and regulation of the actin cytoskeleton. Differentially expressed genes were associated with 123 different gene ontology biological processes: transport, signal transduction, inflammatory response, chemotaxis, and immune response. CONCLUSION We identified that differentially expressed genes are associated with the pathways that are mainly involved in interactions between cells and the extracellular matrix, and with immune function. The reported data provide useful information on the molecular mechanisms underlying the formation of ascending aortic aneurysms.

Recurrent cervical esophageal stenosis after colon conduit failure: use of myocutaneous flap.

A 53-year-old male developed cervical esophageal stenosis after esophageal bypass surgery using a right colon conduit. The esophageal bypass surgery was performed to treat multiple esophageal strictures resulting from corrosive ingestion three years prior to presentation. Although the patient underwent several endoscopic stricture dilatations after surgery, he continued to suffer from recurrent esophageal stenosis. We planned cervical patch esophagoplasty with a pedicled skin flap of sternocleidomastoid (SCM) muscle. Postoperative recovery was successful, and the patient could eat a solid meal without difficulty and has been well for 18 mo. SCM flap esophagoplasty is an easier and safer method of managing complicated and recurrent cervical esophageal strictures than other operations.

Intercostal Lung Hernia after Pectus Bar Removal

A 27-year-old man presented with chest pain and shortness of breath. A chest radiograph revealed collapse of the right lung (Fig. 1); this was his third episode of ipsilateral pneumothorax during the past 3 years. He had a history of minimally invasive repair of pectus excavatum (MIRPE) at another hospital 11 years earlier, and he had undergone surgery for a bar removal 4 years earlier. The computed tomographic scan of the chest revealed deformed ribs, costal cartilages, herniation of both lungs through the chest walls (Fig. 2), and a huge bulla in the right upper lobe. During surgery, the right lung was densely adhered to the parietal pleura, and the medial segment of the right middle lobe was herniated through the chest wall (Fig. 3). We resected the bulla of the right upper lobe and the herniated portion of the right middle lobe with an endostapler after the adhered lung was dissected free due to air leakages from those lobes. Fig. 1 Chest radiograph showing the right pneumothorax. Fig. 2 Computed tomographic scan of the chest showing herniation (arrowhead) of the right middle lobe (A) and the left upper lobe (B). Fig. 3 Intraoperative thoracoscopic view shows the right middle lobe herniated through the intercostal space. Complications related to a pectus bar such as displacement, infection, and allergy make up most of the late postoperative complications [1]. However, intercostal lung hernia after pectus bar removal is rare, and it has not been previously reported on. The patient had had a pectus bar for 7 years, and it may have caused deformities of the ribs and costal cartilages, especially at the sites where it entered and exited the pleural cavity. As a result, intercostal defects were created on each side of the chest wall, and the lungs may have herniated through these defects. Although this type of herniation usually does not cause pulmonary problems such as a reduction of lung function, they can complicate entering the pleural cavity during surgery in the future.

The Effect of Thoracosopic Thoracic Sympathetomy on Pulmonary Function and Bronchial Hyperresponsiveness

Background. Endoscopic thoracic sympathectic denervation (ESD) is a procedure used in primary hyperhidrosis and upper extremity ischemia. Bronchial tone is affected by the sympathetic and parasympathetic nervous systems and bronchial asthma is associated with an imbalance between them. The aim of this study was to evaluate the effects of ESD on pulmonary function and bronchial hyperresponsiveness (BHR). Patients and methods. Fifty-eight patients with primary hyperhidrosis (n = 54) or upper limb ischemia (n = 4) were included. Spirometry and bronchial provocation test with methacholine was performed before and 4 weeks after ESD. Results. Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were significantly decreased early after ESD (from 4.67 ± 0.84 L and 4.36 ± 0.85 L to 4.12 ± 0.78 L and 3.84 ± 0.82 L, respectively), although no patient complained of an aggravation of respiratory symptoms. Twelve patients (21%) had a positive response to methacholine provocation preoperatively, and all remained positive post surgery. The provocative concentration of methacholine, which brought about a 20% decrease in the FEV1 in the patients, was not significantly changed after surgery (from 5.1 ± 4.3 to 4.6 ± 4.6). Of 46 patients who had a negative result for methacholine challenge preoperatively, 12 (26%) became positive after surgery. In terms of the level of sympathectomy, T3 sympathectomy significantly increased the ratio of patients exhibiting a positive response to methacholine (from 19% to 34%, respectively) (p < 0.005). Conclusions. Thoracic sympathectomy can adversely affect lung function early after surgery, although the clinical significance is uncertain. It may also exert an influence on the development of bronchial hyperresponsiveness, especially when performed at the T3 level.

Recurrent intractable hiccups treated by cervical phrenic nerve block under electromyography: report of a case

AbstractIntractable or persistent hiccups require intensive or invasive treatments. The use of a phrenic nerve block or destructive treatment for intractable hiccups has been reported to be a useful and discrete method that might be valuable to patients with this distressing problem and for whom diverse management efforts have failed. We herein report a successful treatment using a removable and adjustable ligature for the phrenic nerve in a patient with recurrent and intractable hiccups, which was employed under the guidance of electromyography.

Extent of removal for mediastinal nodal stations for patients with clinical stage I non-small cell lung cancer: effect on outcome.

BACKGROUND Lobectomy and mediastinal lymph node dissection comprise the standard surgical treatment for non-small cell lung cancer (NSCLC). Although complete mediastinal lymph node dissection has been recommended as part of the procedure for achieving complete resection, the benefits for early lung cancer are unclear. The purpose of this study was to determine the effects of different degrees of mediastinal lymph node dissection on the clinical outcomes of patients with clinical stage I NSCLC. MATERIALS AND METHODS The records of patients with clinical stage I NSCLC treated between January 2000 and September 2010 were reviewed retrospectively. This study consisted of 211 patients who underwent lobectomy plus mediastinal lymph node dissection and sampling. Patients were divided into a group who underwent lymphadenectomy (LA) including complete mediastinal node dissection or lobe-specific lymph node dissection and a group who underwent selective lymph node sampling (LS). Clinical outcomes, including survival, and prognostic factors were determined. RESULTS The mean (±) number of extracted lymph nodes for the LS and LA patients was 7.50 ± 5.44 and 14.09 ± 7.57, respectively (p < 0.001). Male and diabetes mellitus patients were more associated with LS. Survival of the LA patients was significantly longer (p = 0.029). By multivariate analysis, extent of mediastinal nodal sampling (p = 0.029) and positive for mediastinal nodal (N2-positive) disease (p = 0.046) were significant predictors for survival. CONCLUSIONS The extent of dissection of mediastinal lymph nodes affected the clinical outcomes of our study patients with clinical stage I NSCLC. At least evaluation of lobe-specific lymph node dissection is required.

Influence of lung resection volume on risk of primary spontaneous pneumothorax recurrence

Background Thoracoscopic stapled bullectomy is a popular procedure for the treatment of primary spontaneous pneumothorax (PSP) that has a relatively high postoperative recurrence rate. One reason for PSP recurrence is the formation of a new bulla around the staple line. We hypothesized that different resected specimen volumes might cause differences in staple line tension. In this study, we analyzed the relationship between postoperative pneumothorax recurrence and resected lung volume. Methods Between April, 2009 and December 2013, 360 cases which underwent video-assisted thoracoscopic surgery (VATS) for PSP were selected. Recurrence after VATS was examined by electronic medical records and telephone survey. Resected volume and vertical area of specimen were calculated with the size of pathologic specimen. Results A mean follow up period was 44.5±24.4 months and recurrence rate was 11.1% (40/360). Large volume of resected specimen (≥16 cm3) (P=0.027 by the log-rank test) and larger vertical area of resected specimen (≥2.0 cm2) (P=0.003 by the log-rank test) showed significantly high recurrence rate. Cox regression analysis demonstrated that age [hazard ratio (HR), 0.083, P=0.006], vertical section area of resected specimen (HR, 1.239, P=0.020) and volume of resected pathology specimen (HR, 1.039, P=0.009) were independent risk factors of recurrence. Conclusions Bulky resection during VATS for PSP increases the risk of recurrence. Large volume and vertical area of resected specimen are associated with greater tension in stapling line. Avoidance of wide resection and the firing of stapler after full collapse of lung are recommended for reducing the pneumothorax recurrence after VATS.