PURPOSE:We developed a quantitative method to evaluate aortic atheroma and investigated its association with postoperative cerebral infarction (CI) after aortic arch surgery. In addition, computational fluid dynamics (CFD) analysis was performed to explore the underlying hemodynamic mechanisms. METHODS:We retrospectively analyzed 72 patients who underwent aortic arch surgery. Atheroma scores were calculated from preoperative computed tomography, and a qualitative assessment was also performed. Multivariate logistic regression identified risk factors for CI. CFD analysis was conducted in selected patients to provide mechanistic insights. RESULTS:CI occurred in 8 patients (11.1%). Atheroma scores were significantly higher in patients with CI (P = .02), whereas qualitative assessment did not predict CI. Receiver operating characteristic analysis showed an area under the curve of 0.79 for the ascending aorta, with a cutoff of 352.3. Multivariate analysis including age demonstrated that hemoglobin A1c and an ascending atheroma score ≥352.3 were independent predictors of CI. CFD demonstrated high wall shear stress in the ascending aorta, providing mechanistic insight into embolic events. CONCLUSIONS:Quantitative assessment of ascending aortic atheroma provides superior risk stratification compared with qualitative evaluation. CFD findings offer mechanistic insight into embolic risk, supporting the clinical relevance of atheroma burden in aortic arch surgery.
Donor coronary artery disease (CAD) can lead to the discard of otherwise suitable hearts, although selected focal lesions may be treated with concomitant revascularization. We report orthotopic heart transplantation in a 52-year-old man with end-stage ischemic cardiomyopathy and previous coronary artery bypass grafting using a donor heart in which coronary computed tomography angiography showed severe proximal left anterior descending artery (LAD) stenosis with calcified plaque. Before recipient cardiectomy, the recipient's previously constructed, patent left internal mammary artery (LIMA)-to-LAD graft was carefully mobilized, preserved as an arterial conduit, and repurposed for donor-heart revascularization. After implantation, the salvaged recipient LIMA was anastomosed to the donor LAD distal to the stenosis. Transit-time flow measurement confirmed satisfactory graft function. The patient recovered uneventfully, with preserved biventricular function and angiographic LIMA-LAD patency. This case highlights the technical feasibility of reusing a pre-existing recipient LIMA graft to permit transplantation of a donor heart with focal CAD.
A residual false lumen after type A aortic dissection repair may rarely serve as an embolic route to the cerebral circulation. A woman in her 60s underwent ascending aortic replacement for Stanford type A aortic dissection, leaving a residual patent dissection involving the supra-aortic branches and the descending aorta. Despite receiving anticoagulant and antiplatelet therapies, the patient developed recurrent multifocal cerebral infarctions. Transesophageal echocardiography (TEE) demonstrated an entry tear in the descending aorta communicating from the true lumen to the false lumen. Flow became markedly stagnant toward the proximal false lumen, with thrombus-like echogenic material. Four-dimensional computed tomography (4DCT) confirmed delayed retrograde flow ascending within the false lumen toward the arch. Total arch replacement was performed to eliminate the suspected embolic route. Intraoperative findings confirmed thrombotic material within the false lumen. No recurrent cerebral infarctions were observed postoperatively.
Prone minimally invasive esophagectomy offers several technical advantages; however, in obese patients, increased abdominal pressure may contribute to diaphragmatic elevation, leading to difficulty in first-port placement and compromised operability in the lower mediastinum. These technical challenges can be particularly relevant in robot-assisted procedures, where adequate working space and sufficient inter-arm distance are required. We describe a positioning modification using a 4-point support frame in obese patients undergoing prone minimally invasive esophagectomy. By supporting the thorax and pelvis while allowing the abdomen to hang freely, this strategy is intended to reduce abdominal compression and prevent diaphragmatic elevation. In our preliminary institutional experience, this approach facilitated port placement in the standard configuration and provided stable lower mediastinal exposure. Although based on a limited series, this positioning technique may represent a practical and reproducible option for selected obese patients undergoing prone minimally invasive esophagectomy.
PURPOSE:Thoracic surgery is commonly performed for the management of conditions involving the lungs, mediastinum, pleura, and chest wall. Despite advances in surgical techniques and perioperative care, postoperative pain remains a frequent complication. In some patients, pain may persist and progress into chronic post-thoracotomy pain syndrome (CPTPS), defined as pain lasting more than 2 months after surgery. The prevalence of chronic pain ranges from 21% to 91%, with lower rates observed in minimally invasive approaches such as video-assisted thoracoscopic surgery (VATS) (~35.5%) and robotic-assisted thoracic surgery (RATS) (11.2%-34.6%). METHODS:This study presents a literature review evaluating the epidemiology, pathophysiology, and management of CPTPS, including pharmacological, interventional, and rehabilitation-based approaches, as well as emerging biological therapies. RESULTS:Chronic pain is multifactorial, involving tissue injury, inflammation, intercostal nerve damage, and central sensitization. It is associated with impaired respiratory function, reduced mobility, sleep disturbances, and decreased quality of life. Multimodal analgesia and regional anesthesia are key strategies, while rehabilitation supports functional recovery. Emerging biological therapies show promise but remain limited in evidence. CONCLUSION:A multidisciplinary approach is essential to reduce CPTPS and improve long-term outcomes and quality of life.
PURPOSE:Recirculation is a critical issue in veno-venous extracorporeal membrane oxygenation (VV ECMO). We propose a novel method for estimating the recirculation ratio using temporary sweep-gas control. METHODS:A circuit simulating VV ECMO recirculation was constructed by introducing a short circuit between the inlet and outlet of the oxygenator, enabling direct measurement of recirculation flow. Temporary cessation of sweep gas induced decreases in oxygen saturation at the oxygenator inlet (SpreO2) and outlet (SpostO2). The ratio of their temporal changes (⊿SpreO2/⊿SpostO2) converged to the recirculation ratio, reflecting blood mixing. The early prediction phase was defined as the interval required for oxygen saturation to decrease from 99% to 95% after sweep-gas cessation. The method was validated in an acute porcine model. RESULTS:In circuit experiments, the relative prediction error was 7.0% ± 5.2%. Early prediction required 3.0 ± 1.0 s when recirculation was ≤50% and 4.1 ± 1.0 s when >50%. In animal experiments, the error was 7.5% ± 4.0%, with times of 10.4 ± 2.8 s for recirculation ≤50% and 27.8 ± 0.5 s for >50%. CONCLUSIONS:The proposed method enables rapid, less invasive prediction of the recirculation ratio and may provide a practical tool for optimizing ECMO management.
PURPOSE:Patients on hemodialysis (HD) undergoing coronary artery bypass grafting (CABG) face a high risk of perioperative complications, and the optimal timing of perioperative HD remains unclear. We evaluated the safety and feasibility of a standardized HD protocol in patients undergoing off-pump CABG (OPCAB). METHODS:We retrospectively analyzed 64 HD-dependent patients who underwent elective OPCAB at a single institution between March 2014 and December 2024. The protocol included maintaining a Monday-Wednesday-Friday HD schedule, performing routine HD on Monday morning, conducting OPCAB on Monday afternoon, and resuming HD on postoperative day (POD) 2. Clinical outcomes, unplanned dialysis, and perioperative biochemical changes were assessed. RESULTS:Seven patients (10.9%) required unplanned renal replacement therapy before the first postoperative HD session for congestive heart failure (n = 3), hyperkalemia (n = 3), or respiratory failure (n = 1). None required additional dialysis after the initial postoperative HD. In-hospital mortality was 3.1%. Postoperative congestive heart failure occurred in 4.7% of patients. Body weight returned to near baseline by POD 7, and serum potassium remained within an acceptable range throughout the perioperative period. CONCLUSION:This standardized perioperative HD protocol was feasible for maintenance HD patients undergoing elective OPCAB. However, protocol deviation in 10.9% of patients suggests that further refinement and prospective comparative studies are warranted.
We describe a surgical strategy combining on-pump beating-heart coronary artery bypass grafting (OPBH CABG) with left ventricular (LV) venting for patients with advanced ischemic cardiomyopathy (ICM) with severe LV dysfunction and marked LV dilation. This strategy provides LV decompression, reduces myocardial workload, and improves surgical exposure during coronary anastomosis, facilitating complete revascularization. Between January 2013 and September 2024, 7 patients underwent OPBH CABG with LV venting. Six patients had chronic ICM with dilated ventricles and severe systolic dysfunction, and 1 presented with acute coronary syndrome and impaired LV function. The median age was 65 years (interquartile range [IQR], 61-80). The median left ventricular ejection fraction was 21.7% (IQR, 19.2-27.9), and the median left ventricular end-diastolic diameter was 61.6 mm (IQR, 58.7-69.3). Complete revascularization was achieved in all patients without additional mechanical circulatory support. There were no in-hospital deaths or postoperative complications. This strategy may enable complete revascularization in selected high-risk patients while contributing to myocardial unloading.
Purpose: We investigated the clinical significance of lymphovascular invasion (LVI) in locally advanced lung adenocarcinoma after induction chemoradiotherapy (CRT). Methods: We retrospectively reviewed patients with completely resected lung adenocarcinoma after induction CRT from 2007 to 2021 at our institution. We evaluated the effects of LVI on recurrence-free survival (RFS) and overall survival (OS). Results: Fifty-six patients were included. The reasons for induction CRT were superior sulcus tumor (n = 11, 19.6%), direct invasion of other organs (n = 7, 12.5%), bulky N1 (n = 3, 5.4%), and N2 (n = 35, 62.5%). A pathological complete response was observed in 6 patients (10.7%). LVI was present in 14 patients (25.0%) and absent in 42 (75.0%). The LVI-positive group had significantly worse 5-year RFS (7.8%vs. 49.7%, p <0.001) and OS (35.2%vs. 73.5%, p = 0.003) thanthe LVI-negative group. Multivariate analysis revealed that LVI was a significant prognostic factor for both RFS (hazard ratio [HR], 3.91; 95% confidence interval [CI], 1.64-9.32, p = 0.002) and OS (HR, 5.75; 95% CI, 1.92-17.20, p = 0.002). Conclusions: LVI can be a poor prognostic factor and an important biomarker for assessing the effectiveness of multimodal treatment in lung adenocarcinoma.
PURPOSE:This study aimed to compare surgical safety outcomes of uniportal and multiportal video-assisted thoracoscopic surgery (uVATS and mVATS) segmentectomy during institutional adoption, focusing on differences according to lobar location. METHODS:We retrospectively analyzed 117 patients who underwent thoracoscopic segmentectomy between 2019 and 2024 (uVATS, 49; mVATS, 68). Outcomes included intraoperative pulmonary vessel injury and major postoperative complications, along with operative time, blood loss, and length of hospital stay. Inverse probability of treatment weighting was applied, and analyses were performed overall and stratified by lobe. RESULTS:Pulmonary vessel injury occurred in 12 patients (10.3%), and grade ≥III complications in 10 (8.5%). After adjustment, uVATS showed a higher incidence of vascular injury than mVATS overall (22.8% vs. 5.5%; p = 0.006). No statistically significant differences were observed in upper-lobe segmentectomy. In lower-lobe segmentectomy, uVATS showed higher rates of vascular injury (44.8% vs. 2.2%; p <0.001) and grade ≥III complications (18.8% vs. 0%; p = 0.005). CONCLUSIONS:No statistically significant differences were observed between uVATS and mVATS in upper-lobe segmentectomy. However, during the institutional adoption phase, careful consideration is warranted when performing lower-lobe segmentectomy with uVATS due to a higher incidence of complications related to surgical safety.
Purpose: Posterior rib fractures represent severe thoracic trauma and are associated with a higher risk of complications due to their proximity to vital intrathoracic structures, including the intercostal vessels and lungs. Surgical stabilization of rib fractures (SSRF) has emerged as an operative strategy to restore chest wall stability, improve respiratory mechanics, and reduce pain. However, evidence specifically addressing posterior rib fractures remains limited, and current understanding is largely extrapolated from studies involving general rib fracture populations. Methods: This literature review evaluates the principles, operative techniques, effectiveness, and limitations of SSRF in posterior rib fractures, with an emphasis on surgical timing, technical challenges, and postoperative rehabilitation. Results: Current evidence suggests that SSRF may reduce respiratory complications and improve outcomes in selected patients. Studies report reductions in pneumonia incidence and up to a 95% decrease in tracheostomy requirements in patients with flail chest. Surgical timing also influences outcomes, with pneumonia reported in 18% of patients undergoing SSRF within 72 h compared with 58% in those receiving delayed stabilization. Conclusions: SSRF may provide clinical benefits in appropriately selected patients with rib fractures. However, evidence specifically addressing posterior rib fractures remains limited, and further high-quality studies are required to clarify optimal indications and surgical strategies.
PURPOSE:This study aimed to compare outcomes of the modified wrapping technique (MWT) and supracoronary tube replacement (STR) for isolated ascending aortic aneurysms, focusing on perioperative safety, 5-year survival, and arterial stiffness. METHODS:This retrospective, single-center study included 205 patients undergoing MWT (n = 91) or STR (n = 114) between 2006 and 2019 for isolated ascending aortic aneurysms ≥50 mm or rapidly progressing lesions. A prospective substudy evaluated arterial stiffness using the SphygmoCor system in a matched subgroup of 40 patients. The primary endpoint was 5-year survival; secondary endpoints included perioperative outcomes, prosthetic infection, and hemodynamic indices. RESULTS:MWT showed significantly shorter cardiopulmonary bypass and aortic cross-clamp times (p <0.0001) and reduced hospital stay (10.5 ± 0.3 vs. 13.5 ± 0.8 days; p = 0.001). In-hospital mortality tended to be lower with MWT (0% vs. 4.4%; p = 0.06). Five-year survival was comparable between groups (88.1% vs. 83.4%; p = 0.17). Prosthetic infection was significantly lower in the MWT group (1.1% vs. 7.0%; p = 0.04). Hemodynamic assessment demonstrated lower pulse wave velocity and aortic augmentation index in the MWT group. CONCLUSIONS:MWT was associated with shorter operative times and lower prosthetic infection rates while maintaining similar early and mid-term survival compared with STR. These findings suggest MWT as a valuable alternative in selected patients.
Purpose: The aim of this study was to evaluate the effectiveness of closed-incision negative pressure wound therapy (ciNPWT) as a prophylactic measure to prevent deep sternal wound infection (DSWI) after surgery. Methods: A total of 209 patients undergoing isolated coronary artery bypass grafting via median sternotomy were enrolled. The patients were divided into 3 groups according to incisional care. In Group A (n = 63), the wound was covered with sterile gauze dressings alone. In Group B (n = 71), an indwelling subcutaneous drain was placed and the wound was covered with a hydrocolloid dressing. In Group C (n = 75), an indwelling subcutaneous drain was placed and the wound was covered with a ciNPWT device (PICO; Smith & Nephew). The incidence of DSWI occurring within 60 postoperative days was compared among the 3 groups. Results: There were no significant differences in preoperative, operative, or postoperative variables among the groups. Postoperative DSWI occurred in 11.1% (7/63) of patients in Group A and 5.6% (4/71) of patients in Group B, whereas no patients in Group C developed DSWI. Conclusions: Immediate application of NPWT was associated with a reduced rate of wound infection. This treatment may represent an effective preventive strategy.
PURPOSE:Cranial migration of the right middle lobe (RML) after right upper lobectomy may cause bronchial angulation and alter postoperative lung volume distribution. We investigated whether RML fixation techniques affect postoperative lobar volume and pulmonary function. METHODS:This retrospective single-center study included 96 patients who underwent right upper lobectomy for non-small cell lung cancer (2009-2020). Patients were classified into 3 groups: no fixation, normal fixation, and sliding (anterior-caudal) fixation of the RML to the right lower lobe (RLL). Lobar volumes were assessed using 3-dimensional computed tomography volumetry, and postoperative pulmonary function tests were analyzed when available. RESULTS:Both lower lobes showed significant compensatory expansion, with the RLL demonstrating the largest increase. Overall, RML volume did not change significantly. However, RML volume increased in the normal fixation group (+58.9 ± 78.2 mL) but decreased in the sliding-fixation (-29.0 ± 92.6 mL) and no-fixation groups (-16.9 ± 118.9 mL), with significant differences among groups (p <0.001). Postoperative changes in forced vital capacity and forced expiratory volume in 1 second did not differ among groups, and RML volume change was not correlated with pulmonary function. CONCLUSIONS:Normal RML fixation preserved RML volume after right upper lobectomy, but did not improve postoperative pulmonary function. Further studies are warranted.
Durvalumab maintenance therapy following chemoradiotherapy is the standard treatment for patients with unresectable stage III non-small-cell lung cancer. Immune checkpoint inhibitors can alter host immunity, potentially amplifying inflammatory responses during opportunistic infections. We report a rare case of rapidly progressive destroyed lung caused by invasive pulmonary aspergillosis during durvalumab therapy, which was successfully managed with salvage pneumonectomy. A 53-year-old man with locoregionally recurrent lung adenocarcinoma received chemoradiotherapy followed by durvalumab treatment. Invasive pulmonary aspergillosis developed on day 74. Despite intensive antifungal therapy and corticosteroid administration, the right lung developed extensive liquefactive necrosis beyond the irradiated field within 5 weeks. Given the risk of fatal hemoptysis and sepsis, an emergency right pneumonectomy was performed. The frozen hilum required intrapericardial vascular control and reinforcement of the bronchial stump. Recovery was uneventful, and pathological examination confirmed aspergillosis without residual malignancy. Prompt recognition of medical refractoriness and timely surgery are critical for survival.
Primary cardiac intimal sarcoma is an extremely rare, high-grade malignancy characterized by rapid progression and high early recurrence rates. We report the case of a 28-year-old male who underwent emergency resection for a large left atrial intimal sarcoma (10 × 8 cm). Follow-up imaging at 6 months revealed a 15-mm recurrent tumor infiltrating the left atrial septum, despite an initially stable recovery. We prioritized radical resection over surgical risk, given the patient's youth and the aggressive behavior of the tumor. Therefore, a "Commando" procedure consisting of radical tumor resection, double valve replacement, and reconstruction of the intervalvular fibrosa using the Manouguian technique was performed. Histopathological examination confirmed recurrent intimal sarcoma with negative surgical margins. Despite its high invasiveness, the Commando procedure is viable for primary treatment for recurrent cardiac intimal sarcomas in young patients. Aggressive surgical reconstruction remains the only viable option to improve the prognosis of this otherwise fatal malignancy.
Tracheomediastinal fistula is a rare but potentially life-threatening complication associated with malignant lymphoma. We report a case of spontaneous closure of a tracheomediastinal fistula that developed after chemotherapy for mediastinal diffuse large B-cell lymphoma (DLBCL). A 70-year-old man presented with airway compression caused by a large mediastinal tumor. After airway stabilization with a Dumon Y stent and subsequent R-CHOP chemotherapy, the tumor markedly regressed. Following stent removal, a fistula developed in the anterior tracheal wall, communicating with a necrotic mediastinal space. Because no clinical or laboratory signs of mediastinitis were observed, conservative management without antibiotics or invasive intervention was adopted. The fistula gradually decreased in size and closed completely within 10 weeks. This case suggests that tracheomediastinal fistulas without mediastinitis may be managed conservatively under careful observation. Treatment strategies should be individualized based on anatomical location and the presence or absence of infection.
Purpose: Although immune checkpoint inhibitor-based perioperative therapy has become the standard for resectable stage IIIA-N2 non-small cell lung cancer (NSCLC), not all patients are eligible for this approach. This study evaluated long-term outcomes of histology-based induction chemoradiotherapy (CRT) followed by surgery. Methods: This prospective observational study enrolled 48 consecutive patients with pathologically confirmed stage IIIA-N2 NSCLC between April 2010 and May 2025. Patients with squamous cell carcinoma (Sq) received cisplatin/vinorelbine, while those with non-squamous cell carcinoma (non-Sq) received cisplatin/pemetrexed, both with concurrent radiotherapy (50 Gy), followed by surgery. Results: All 48 patients (25 Sq, 23 non-Sq) completed induction CRT; 45 (93.8%) underwent surgery, with 97.8% achieving complete resection. Median follow-up was 48.8 months. The 5-year overall survival/disease-free survival (DFS) rates were 77.9%/77.3% for Sq and 70.5%/33.7% for non-Sq cohorts. Grade 3/4 toxicities were more frequent in Sq patients (80.0% vs. 21.7%, p <0.001). Exploratory analysis revealed inferior DFS in epidermal growth factor receptor (EGFR)-mutated non-Sq patients, though overall survival remained favorable with subsequent tyrosine kinase inhibitor therapy. Conclusion: Histology-based induction CRT followed by surgery demonstrated feasibility and favorable outcomes, particularly for Sq and EGFR-negative non-Sq NSCLC. These findings provide a reference for patients ineligible for immune checkpoint inhibitor-based therapy.
Post-tuberculosis airway stenosis can cause fixed cicatricial narrowing and long-term disability. We report a female patient with recurrent upper tracheal restenosis despite 2 prior resections, who presented decades later with respiratory failure; intubation was impossible, necessitating emergency tracheostomy. Imaging and bronchoscopy revealed pinhole stenosis near the second tracheal ring and left main bronchial stenosis with a destroyed left lung. The patient remained tracheostomy-dependent and aphonic after infection control. Because repeat resection was high-risk and endoscopic stent delivery was infeasible, a Dumon silicone stent was inserted via transcervical longitudinal tracheotomy under direct vision. Airway patency and phonation improved, and follow-up showed a stable stent without major complications. This open approach may serve as a salvage surgery when endoscopic delivery is impossible.
PURPOSE:The optimal method of pericardial closure in lung transplantation remains controversial. This study aimed to evaluate the technical feasibility and procedural simplicity of pericardial closure using donor pericardium. METHODS:We retrospectively reviewed 70 adult patients who underwent deceased-donor bilateral lung transplantation with cardiopulmonary bypass or central extracorporeal membrane oxygenation between December 2010 and January 2024 at Kyoto University Hospital. Patients were divided into the Donor pericardium group (n = 21) and the Autologous tissue group (n = 49). Pericardial closure time was assessed as an indicator of procedural simplicity, and postoperative complications within 1 year were descriptively evaluated. RESULTS:Baseline characteristics did not differ between the groups. Mean pericardial closure time was significantly shorter in the Donor pericardium group than in the Autologous tissue group (13 ± 2.4 vs 19 ± 1.6 min, P = 0.03). No clinically concerning differences in postoperative complications were observed during short- to mid-term follow-up. CONCLUSION:Pericardial closure using donor pericardium enables technically simpler and faster closure without apparent short-term safety concerns.
