General Thoracic and Cardiovascular Surgery

Publications in this journal

• Article: Minimally invasive pulmonary surgery for lung cancer, up to date.

  Hisashi Iwata
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  ABSTRACT: Recently, the minimally invasive surgical approach is an important issue in the pulmonary surgery. In this review, we present the current fashion of video-assisted thoracic surgery (VATS) and new approach including robotic lobectomy. There is no clear definition or standard for this surgical procedure regarding VATS lobectomy. Therefore, no randomized controlled trial of VATS and conventional lobectomy can be set up. Although the definition of VATS lobectomy is not straightforward, VATS lobectomy showed the technical feasibility of conventional lobectomy in mortality and postoperative complication as well as lymph node dissection. VATS procedure for advanced lung cancer is unclear whether such observations can be developed into a standardized approach. There are no reports to evaluate the advantages of robotic lobectomy in terms of treatment outcomes for lung cancer compared with VATS lobectomy. However, we believe that robotic lobectomy has clear potential to improve the quality of minimally invasive surgery.
  General Thoracic and Cardiovascular Surgery 05/2013;
• Article: Current status of minimally invasive esophagectomy for patients with esophageal cancer.

  Hiroya Takeuchi, Hirofumi Kawakubo, Yuko Kitagawa
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  ABSTRACT: Technical advancements and development of endoscopic equipment in thoracoscopic surgery have resulted in increase in the popularity of minimally invasive esophagectomy (MIE). However, advantages with regard to short-term outcome and oncological feasibility of MIE have not been adequately established. To date, a number of single-institution studies and several meta-analyses have demonstrated acceptable short-term outcomes of thoracoscopic esophagectomy for esophageal cancer, and the outcomes are comparable to those of conventional open esophagectomy (OE). A study group recently reported the results of the first multicenter randomized controlled trial (RCT) that compared MIE and OE. The incidence of pulmonary infection after surgery was markedly lower in the MIE group than in the OE group. Additional benefits of MIE included less operative blood loss, better postoperative patients' quality of life, and shorter hospital stay. However, the oncological benefit to patients undergoing MIE has not been scientifically proven because there have been no RCTs to verify the equivalency in long-term survival of patients undergoing MIE compared with that of patients undergoing OE. If future prospective studies indicate oncological benefits, MIE could truly become the standard care for patients with esophageal cancer.
  General Thoracic and Cardiovascular Surgery 05/2013;
• Article: Parietal pleural hematoma: plausible aortic dissection in an octogenarian on multiple antiplatelets, coumadin and oral steroids.

  Hideyuki Katayama, Takeshi Shimamoto, Genichi Sakaguchi, Shinichi Ijuin, Tatsuhiko Komiya
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  ABSTRACT: An 84-year-old male on oral steroids, coumadin and multiple antiplatelets for stented superficial femoral artery presented to our hospital with chest oppression. His CT scan showed cardiac tamponade with periaortic hematoma. At first, sealed rupture of aortic dissection with thrombosed false lumen was suspected. However, delayed enhancement view revealed extravasation of contrast agent, which appeared to drain into the pericardium or pericardial space. Emergency thoracotomy revealed normal aorta with several small spurting vessels of pulmonary side of the pericardium. To the best of our knowledge, this is the first reported case in the literature of a parietal pleural hematoma without known cause such as malignancy or hematologic disorders.
  General Thoracic and Cardiovascular Surgery 05/2013;
• Article: Modified Konno procedure: surgical management of tunnel-like left ventricular outflow tract stenosis.

  Yukihiro Takahashi, Yoshikatsu Hanzawa
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  ABSTRACT: Left ventricular outflow tract stenosis represents 1-2 % of all congenital anomalies. In particular, tunnel-like left ventricular stenosis which is one type of fixed left ventricular outflow stenosis requires aggressive surgery to reduce the left ventricular outflow gradient. The purpose of the modified Konno procedure is to release fixed left ventricular outflow tract stenosis while preserving the native aortic valve and its function. Although the clinical results of the modified Konno procedure are acceptable, it is necessary to precisely understand this procedure and the anatomy of the left ventricular outflow tract in order to avoid complications.
  General Thoracic and Cardiovascular Surgery 05/2013;
• Article: Mitral valve endocarditis in a patient with Ehlers-Danlos syndrome.

  Ioannis Koukis, Jennifer Kingston, Panagiotis Dedeilias, Brian Prendergast
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  ABSTRACT: We report a patient with Ehlers-Danlos syndrome and mitral valve endocarditis. The case was complicated due to the initial septic status of the patient and the fragility of the mitral valve both of which required further early operative intervention. The patient also had pre-existing pulmonary septic emboli, the significance of which was missed prior to the admission to our Unit. Two peripheral arterial aneurysms were identified and corrected surgically on same admission. Possible complications of the syndrome and surgical implications are discussed along with review of the literature.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Thoracoscopic resection of a giant mediastinal parathyroid cyst.

  Andrea Dell'amore, Nizar Asadi, Tommaso Bartalena, Alessandro Bini, Franco Stella
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  ABSTRACT: Parathyroid cysts are a rare situation, unusually in the mediastinum. The preoperative diagnosis could be more difficult in some atypical topographies and imaging characteristics in particular in case of huge mediastinal cyst. In the following years traditionally, in case of intrathoracic parathyroid cysts, sternotomy or thoracotomy have been the preferred approaches. We report a case of an older patient with a huge mediastinal parathyroid cyst removed successfully using videothoracoscopy.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Reconstruction of anterior mitral leaflet using autologous pericardial patch combined with posterior leaflet sliding for active infective endocarditis.

  Satoshi Kimura, Yuta Yamaki, Masayoshi Umesue
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  ABSTRACT: We report a case of active infective endocarditis in a young adult, affecting the anterior and posterior leaflets extensively. The patient underwent a mitral valve repair with extended sliding repair on the posterior leaflet and reconstruction using an autologous pericardial patch supported by an artificial chord on the anterior leaflet. Although we finally needed commissure closing for successful repair, we aggressively achieved a repair-oriented strategy using several techniques in a young patient who may have required mitral valve replacement.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Spontaneous innominate and left common carotid artery dissection with bovine aortic arch.

  Satoshi Ohki, Tamiyuki Obayashi, Tetsuya Koyano, Kiyomitsu Yasuhara, Hanako Hirai, Kyouhei Hatori
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  ABSTRACT: We describe a case of a 63-year-old woman who presented with spontaneous dissection of the innominate and left common carotid arteries arising from a common trunk, so-called "bovine aortic arch." The entry tear was seen in the common trunk at the origin of the innominate artery with no dissection extending into the aortic arch or the ascending aorta. The dissection was resected and total arch replacement was performed considering the aortic wall fragility complicated by the dissection.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Finite element analysis regarding patch size, stiffness, and contact condition to the endocardium in surgery for post infarction ventricular septal rupture.

  Toshiaki Ito, Hiroaki Hagiwara, Atsuo Maekawa, Takenori Yamazaki
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  ABSTRACT: BACKGROUND: The purpose of this study is to establish a rational surgical design to minimize suture line stress of the patch and thus prevent residual leakage in surgery for post infarction ventricular septal rupture (VSR). METHODS: A computer model that simulates surgery for VSR was developed. Stress force on the suture line of the patch was calculated at varying size, stiffness, and contact condition of the endocardial patch to the inner surface of the heart using a finite element analysis. Clinical results and echo findings of 34 consecutive patients with a mean age of 72.6 ± 9.5 (range 55-89) who underwent emergency surgery for VSR from 1995 to 2012 were reviewed. RESULTS: Suture line stress decreased by two-thirds as the size or stiffness of the patch increased in comparison with the basic conditions that mimic a pericardial patch fitted to the septal plane. On the other hand, suture line stress increased sixfold when there was a dead space beneath the patch. 30-day mortality was 12 %, and in-hospital mortality 18 %. On echocardiography, all three patients who had dead space beneath the patch had residual leak. Another patient who had huge posterior defect also showed residual leak. Clinical results were well matched to model results. 5-year survival rate of all patients who received operation was 68.7 ± 9.3 %. CONCLUSION: In endocardial patch type surgery for VSR, proper sizing of the patch to sufficiently fit to endocardial surface in a tension-free condition is the most important to avoid residual leak.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Multiple papillary fibroelastoma: report of a case and implications for management.

  Mitsuru Sato, Kouichi Nagaya, Masaharu Hatakeyama, Tsunehiro Komatsu
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  ABSTRACT: A 59-year-old woman with chest discomfort was transferred to our hospital. Echocardiography was suggestive of multiple papillary fibroelastoma (PFE). Tumors on both the left and right coronary cusps were confirmed macroscopically and pathologically and a small tumor was noted microscopically on the non-coronary cusp. Aortic valve replacement was successfully performed. The treatment and recurrence rate of PFE is controversial due to its rarity. Given that multiple tumors were seen in the present case and that possible recurrence has been reported elsewhere, valve replacement may be a better choice for surgical repair than valvoplasty in some cases, such as a single PFE in which plasty may be difficult or multiple PFEs regardless of impaired valve function.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Reversal of acute monoparesis following thoracoabdominal aortic aneurysm repair.

  Naoto Fukunaga, Mitsuru Yuzaki, Michihiro Nasu, Yukikatsu Okada
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  ABSTRACT: A 67-year-old man underwent surgical repair for a Crawford extent V thoracoabdominal aortic aneurysm under cerebrospinal fluid drainage and motor evoked potential monitor on distal aortic perfusion. Postoperatively, weakness of right-sided leg graded 2/5 and bladder disorder were recognized. Magnetic resonance imaging revealed hyperintensity between Th11 and L1 on T2-weighted image. Intravenous glycerin and edaravone for spinal cord ischemia had been administered. The strength of right leg resolved completely with disappearance of hyperintensity on magnetic resonance image. Finally, he could walk on foot with bladder disorder.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Medical teleconferencing with high-definition video presentation on the 'usual' Internet.

  Toshiro Obuchi, Hiroji Shima, Akinori Iwasaki
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  ABSTRACT: Although medical teleconferences on advanced academic networks have been common (Telemed J E Health 15:112-117, 1; Asian J Endosc Surg 3:185-188, 2; Surg Today 41:1579-1581, 3; Telemedicine development center of Asia. http://www.aqua.med.kyushu-u.ac.jp/eg/index.html . Accessed 6 March 2013, 4), reports regarding 'usual' Internet teleconferences or tele-lectures employing a telecommunication system for business use are very rare. Medical teleconferences and tele-lectures on the Internet were held three times between our institutions and other institutions, using the 'HD Com' made by Panasonic (HD Com. http://panasonic.biz/com/visual/ . Accessed 6 March 2013, 5), which is a high-definition telecommunication system for business tele-meeting. All of our medical telecommunications were successfully completed without any troubles. This system allows for all kinds of presentations using personal computers to be made from each station, so that discussions with high-definition surgical video presentation, which has recently been developed, could be effortlessly established despite the distance between institutions. Unlike telecommunication using advanced academic networks, this system can run without any need for specific engineering support, on the usual Internet. Medical telecommunication employing this system is likely to become common among ordinary hospitals in the near future.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Update on aortic valve prosthesis-patient mismatch in Japan.

  Yoshimasa Sakamoto, Kazuhiro Hashimoto
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  ABSTRACT: The influence of aortic valve prosthesis-patient mismatch (VP-PM) on the clinical outcome has been an ongoing controversy. The reported prevalence of VP-PM after aortic valve replacement (AVR) ranges widely between 20 and 70 %. The inconsistent impact of VP-PM on short-term and long-term mortality, regression of left ventricular (LV) hypertrophy, and exercise capacity may be explained by differences of the patient populations, the definition of VP-PM, and the use of different prostheses. Moreover, many factors other than the severity of VP-PM should be taken into account when considering its impact on individual patients after AVR. Although the concept of VP-PM is easy to understand, it cannot be applied to the whole patient population. In Japan, the age of the candidates for AVR has increased markedly in recent years, but almost all elderly patients with a small BSA (<1.6 m(2)) have received newer-generation prostheses with a small outer diameter and large effective orifice area. Indeed, previous studies of Japanese patients have demonstrated that VP-PM was no more than moderate in most cases and its impact on clinical outcomes was generally acceptable. Although severe VP-PM is infrequent and its clinical implications are still unproven in elderly Japanese patients, it would seem reasonable to try to prevent severe VP-PM. Thus, VP-PM itself cannot be accepted as an independent risk factor in Japanese patients, but the useful preventive strategies for severe VP-PM in inactive very elderly persons remain controversial. The implantation of newer-generation biological or mechanical prostheses with or without aortic annular enlargement should be considered according to the characteristics of the patient and the risk-benefit ratio for carrying out a particular procedure in an individual patient.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Isolated mediastinal amyloidosis mimicking a neoplastic lesion.

  Alfonso Fiorelli, Marina Accardo, Giuseppe Ciancia, Guido Pettinato, Mario Santini
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  ABSTRACT: Isolated mediastinal amyloidosis is a rare condition. We report an unusual case of amyloid presented as an isolated mass, entirely confined within anterior mediastinum and FDG-avid, mimicking a neoplastic lesion. Because the differential diagnosis included several diseases as lymphoma, a biopsy via mediastinotomy was attended to avoid unnecessary sternotomy. The pathological results diagnosed to be an amyloidosis. The patient was asymptomatic and biopsy allowed an exact diagnosis, thus we decided against the complete excision. No monoclonal gammopathy and/or amyloid deposition were found. Thus, other treatments as high-dose melphalan and/or autologous stem cell transplantation were not indicated.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Treatments for esophageal cancer: a review.

  Hiroyuki Kato, Masanobu Nakajima
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  ABSTRACT: Esophageal cancer is the eighth most common form of cancer worldwide. The treatments for esophageal cancer depend on its etiology. For mucosal cancer, endoscopic mucosal resection and endoscopic submucosal dissection are standard, while for locally advanced cancer, esophagectomy remains the mainstay. The three most common techniques for thoracic esophagectomy are the transhiatal approach, the Ivor Lewis esophagectomy (right thoracotomy and laparotomy), and the McKeown technique (right thoracotomy followed by laparotomy and neck incision with cervical anastomosis). Surgery for carcinoma of the cervical esophagus requires an extensive procedure with laryngectomy in many cases. When the tumor is more advanced, neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy is added. The theoretical advantages of adding chemotherapy to the treatment of esophageal cancer are potential tumor down-staging prior to surgery, as well as targeting micrometastases and, thus, decreasing the risk of distant metastasis. Cisplatin- and 5-fluorouracil-based regimes are used worldwide. Chemoradiotherapy is the standard for unresectable esophageal cancer and could also be considered as an option for resectable tumors. For patients who are medically or technically inoperable, concurrent chemoradiotherapy should be the standard of care. Although neoadjuvant chemoradiotherapy followed by surgery or salvage surgery after definitive chemoradiotherapy is a practical treatment; judicious patient selection is crucial. It is important to have a thorough understanding of these therapeutic modalities to assist in this endeavor.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Current treatment of active infective endocarditis with brain complications.

  Takashi Miura, Kiyoyuki Eishi
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  ABSTRACT: We describe the optimal timing of surgery in active infective endocarditis patients with brain complications. (1) Non-hemorrhagic infarction: elective surgery has been recommended in patients with non-hemorrhagic infarction. However, the timing is changing to an earlier phase. Recent studies have shown that silent brain embolism and small-size infarction (15-20 mm) without coma can be operated safely without delay. On the other hand, in patients with large non-hemorrhagic infarction with impaired consciousness, early surgery is not recommended. (2) Non-ruptured infectious intracranial aneurysm: treatment strategies for patients with infectious aneurysms without rupture remain controversial. However, the treatments are generally as follows. If the intracranial aneurysm without rupture decreases in size by administration of effective antibiotics, neurosurgery will not be required and cardiac surgery can be prioritized without delay. When the aneurysm without rupture enlarges and changes its morphology, neurosurgery or endovascular surgery should be prioritized to prevent its rupture. (3) Hemorrhagic stroke: this type is classified into primary intra-cerebral hemorrhage due to simple necrotic arteritis, hemorrhagic transformation of ischemic infarcts, and rupture of intracranial infectious aneurysms. Among these, primary intracerebral hemorrhage is the most frequently observed. In patients with the primary intracerebral hemorrhage, surgery must be postponed for at least 4 weeks to prevent exacerbation of bleeding. In patients with ruptured infectious aneurysm, neurosurgery or endovascular surgery is performed initially and cardiac surgery should be postponed at least 2-3 weeks.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Changing strategy for aortic stenosis with coronary artery disease by transcatheter aortic valve implantation.

  Junjiro Kobayashi
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  ABSTRACT: Coronary artery disease (CAD) is combined with aortic stenosis (AS) in 40-50 % of patients with typical angina. Recently, transcatheter aortic valve implantation (TAVI) has changed the guideline for AS in patients with high comorbidity. At the same time more than 60 % of isolated CABG has been performed without cardiopulmonary bypass in Japan. CABG is recommended and should be considered in patients with primary indication for AVR and luminal stenosis >70 % in major coronary arteries and the left internal thoracic artery (LITA) by guidelines. AVR is indicated for severe AS undergoing CABG. It is generally accepted to perform AVR for moderate AS at the time of CABG by valve guidelines. However, prophylactic AVR for moderate AS associated with CABG may increase the early operative risk and expose the patients to postoperative long-term valve related complications. AVR after previous CABG poses potential risk for mortality and morbidity. The presence of patent ITA is a significant risk of its injury and difficulty of myocardial protection during aortic cross-clamping. Therefore, at present, for severe AS previous CABG with patent ITA should be one of the definite indications of TAVI. Rationale of TAVI in patients with severe AS and CAD has not been clearly delineated. The safety of TAVI irrespective of the extent and anatomy of CAD is still controversial. PCI is not appropriate before TAVI in high-risk patients with CAD. In the near future hybrid TAVI will be realistic considering least operative mortality and morbidity in high-risk patients.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Surgical resection of a giant mediastinal teratoma occupying the entire left hemithorax.

  Yuhei Yokoyama, Fengshi Chen, Hiroshi Date
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  ABSTRACT: An 11-year-old female was referred to our hospital with a giant mediastinal mass occupying the entire left hemithorax. Percutaneous biopsy showed no evidence of immature components or malignant cells. Since the tumor compressed the vital structures of the mediastinum with total atelectasis of the left lung, we performed median sternotomy with left anterior thoracotomy. The tumor was punctured, and part of its fluid content was aspirated to achieve reduction in the size of the mass, making tumor resection easier. The tumor was totally resected without complications. A mediastinal tumor occupying the entire hemithorax is uncommon; its surgical strategy is discussed in this manuscript.
  General Thoracic and Cardiovascular Surgery 04/2013;
• Article: Pyothorax-associated lymphoma: complete remission achieved by chemotherapy alone.

  Tomoki Nakagawa, Takayuki Nakano, Ryota Masuda, Masayuki Iwazaki, Ichiro Kuwahira, Naoya Nakamura, Kenji Nakano
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  ABSTRACT: We present the case of a patient with malignant lymphoma resulting from chronic pyothorax after artificial pneumothorax for pulmonary tuberculosis. The 81-year-old female patient had a medical history of artificial pneumothorax from left pulmonary tuberculosis when she was 23 years old and subsequent chronic pyothorax. She had become aware of pain in the left back from October 2008. Chest computed tomography revealed a tumor measuring 61 mm × 27 mm behind the left sixth and seventh ribs. After biopsy revealed pyothorax-associated lymphoma, 4 courses of R-CHOP therapy were administered, leading to complete remission. No recurrences were noted during follow-up over a 4-year period after the initiation of therapy.
  General Thoracic and Cardiovascular Surgery 03/2013;
• Article: Early pseudoaneurysm formation after the sutureless technique for left ventricular rupture due to acute myocardial infarction.

  Kenichi Sasaki, Toshihiro Fukui, Minoru Tabata, Shuichiro Takanashi
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  ABSTRACT: Left ventricular free wall rupture is a fatal and catastrophic complication after acute myocardial infarction. The sutureless technique with a fibrin tissue-adhesive collagen fleece is reportedly safe and effective in the oozing type of left ventricular free wall rupture. However, late pseudoaneurysm formation after this technique has been reported. We herein report a 65-year-old male patient who presented with pseudoaneurysm formation 8 days after the sutureless technique for the oozing type of left ventricular free wall rupture. Successful repair of the pseudoaneurysm was subsequently performed. Pseudoaneurysm formation should be recognized even early after the sutureless technique.
  General Thoracic and Cardiovascular Surgery 03/2013;