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This report discusses the treatment and outcomes of three-port video-assisted thoracoscopic surgery (VATS) thymectomy for thymoma. We reviewed perioperative results of 159 thymoma cases( excluding thymic carcinoma) over 16 years. Thoracoscopic surgery was indicated for Masaoka stagesⅠ to Ⅲ, tumor diameter up to 12 cm, and resection of surrounding organs up to the lung, pericardium+reconstruction, internal thoracic artery and vein, left brachiocephalic vein, and phrenic nerve+reconstruction. The mean age of patients was 56.9±12.7, with 71 males and 88 females. The surgical approach was right-sided in 110 cases, left-sided in 47 cases, and bilateral in 2 cases. Total thymectomy was performed in 141 cases, with total thymectomy plus combined resection of other organs (lungs, pericardium, and phrenic nerve) ±reconstruction in 18 cases. The World Health Organization( WHO) classification( 5th edition) was type A/AB/B1/B2/B3/micronodular thymoma with lymphoid stroma (MNTLS) = 20/49/32/45/11/2, and Masaoka classification was stageⅠ/Ⅱ/Ⅲ=69/86/4. The three-port VATS technique offers several advantages, including its applicability to other surgeries, avoidance of contralateral thoracic cavity opening, safety in thymectomy without open conversion, and a mean postoperative hospital stay of 3 days.

The treatment contents and the outcome of three-port thoracoscopic surgery for multiple lung cancer are studied and discussed in this report. 239 cases of synchronous or metachronous multiple lung cancer (11.5%) out of 2,076 cases of primary lung cancer resected in our department from the year of 2010 to 2018 are subjected to this study. There are 158 cases of synchronous multiple lung cancer and 81 cases of the metachronous. The pathological findings for both synchronous and metachronous multiple lung cancer are adenocarcinoma for 194 cases. The pathological stages for the both are stageⅠfor 208 cases. For the synchronous group, there are 156 cases, in which the patients underwent one-stage surgery was performed. For metachronous group, lobectomy was performed for the first surgery in 69 cases. For the second surgery, bilateral lobectomy was performed in the 13 cases, and there was one case of right completion pneumonectomy. There was no intraoperative death or critical postoperative complication. The five-year survival rates are 84.9% for the synchronous group, and 75.2% for the metachronous group. Above all, three-port thoracoscopic surgery for multiple lung cancer was carried out safely. Bilateral lobectomy and completion pneumonectomy are also possible for metachronous multiple lung cancer if a patient has a decent lung function and good performance status. Especially for stageⅠcases, we could expect a good prognosis, and therefore surgical treatment should actively be performed.

We evaluated the effectiveness of pulmonary vein isolation (PVI) with bipolar radiofrequency ablation in prevention of atrial fibrillation during the acute postoperative period following open-heart surgery. Twenty-six patients with paroxysmal atrial fibrillation (PAF) underwent elective open-heart surgery combined with PVI using bipolar radiofrequency ablation from October 2004 to January 2006. They consisted of 17 male and 9 female with the mean age of 64.2 +/- 8.6 years. Their structural heart disease included coronary artery disease, aortic valve disease, and mitral valve disease. PVI was performed on the bilateral pulmonary vein antra under beating heart using cardiopulmonary bypass. The bipolar radiofrequency system included Atricure (n = 19) and Cardioblate (n = 7). There was no operative death nor complication related to bipolar radiofrequency ablation. In principle, no anti-arrhythmic drugs except beta-blockades were administered postoperatively. In 24 of 26 (92.3%) patients, the sinus rhythms were restored without PAF during the 2 week postoperative period. Even in cases with preoperative PAF, PVI was effective in preventing atrial fibrillation during the acute phase following open-heart surgery. We suggest that bipolar radiofrequency ablation is an alternative procedure to prevent atrial fibrillation in open-heart surgery.

In using the proximal anastomotic system, the anastomotic site should be carefully selected to prevent the kinking of the graft, because the angle of the graft and the aortic wall is perpendicular. There recommended anastomotic sites are the left lateral aortic wall adjacent to the pulmonary artery for the left coronary system grafting and the lower aortic wall adjacent to the right atrium for the right coronary system grafting respectively. When the selection of these sites are difficult because of the atherosclerotic lesion of the aorta, the short vein graft (2-3 cm) was first anastomosed with PAS-Port device to the site free from atherosclerosis. Then, the long vein graft was anastomosed to the short graft with monofilament suture under end-to-side fashion. The angle of the anastomosis was decided according to the relationship of the aorta and the target coronary artery to establish a smooth graft line. By this stepwise technique, the optimal graft design could be obtained without a risk of the kinking of the graft.

During the perioperative period for off-pump coronary artery bypass surgery (OPCAB) and on-pump coronary artery bypass surgery (on-pump CABG), the volume of extra cellular fluid (ECF) was measured. The subjects were elective adult coronary artery bypass surgery cases, consisting of 13 OPCAB cases and 7 on-pump CABG cases. The ECF volume was measured the day before surgery, immediately after surgery, and 2, 4, 6, 8, 12, 24 and 48 hours after surgery, with a bioimpedance analyzer (XITRON 4000 C). ECF volume variation was defined as the difference from the preoperative value divided by body weight, and was expressed in %BW. At the same time, respiratory-index and leukocyte count were measured. The maximum postoperative ECF volume was 3.13 +/- 2.6 %BW in the OPCAB group and 5.36 +/- 2.0 %BW in the on-pump CABG group, that is, significantly higher in the on-pump CABG group. The ECF volume started to increase in the on-pump CABG group immediately after surgery (4.38 +/- 1.8 %BW in the on-pump CABG group and 2.07 +/- 2.4 %BW in the OPCAB group), reaching its peak 6 hours after surgery in the on-pump CABG group and 4 hours after surgery in the OPCAB group. Thereafter, the volume gradually decreased, and 48 hours after surgery the volume decreased in the OPCAB group to 0.064 +/- 1.5 %BW, or to about the same value as the preoperative value, whereas in the on-pump CABG group the volume remained high: 1.9 +/- 2.9 % BW. There was no significant difference between the 2 groups in the change in respiratory-index. The leukocyte count remained significantly higher in the on-pump CABG group. The ECF volume was measured by the bioimpedance measuring method. This is a useful method of measuring the volume non-invasively and continuously. In the OPCAB group, the increase in postoperative ECF volume was less, and recovery to the preoperative level was faster than in the on-pump CABG group.

Extracellular fluid (ECF) was assessed before and after the cardiac surgery using cardiopulmonary bypass (CPB), by means of a bioimpedance spectrum analyzer to see volumes of the fluid based on changes of the impedance to various frequencies. Difference between the levels before and after the operation was divided by body weight to study about a % BW. Simultaneously its relation to the lung compliance [tidal volume/(peak inspiratory pressure-end expiratory pressure)] was studied. Mean age of the 18 patients was 59.1 +/- 19 years old. ECF was assessed before to 24 hours after the operation continuously and once more after 48 hours. Mean CPB time was 165 +/- 52 minutes, and aortic cross clamp time was 121 +/- 4 minutes. A remarkable increase of ECF was noted immediately after the operation, which further increased gradually till arriving at the peak 4 hours after the operation (4.52 +/- 1.8% BW). Then it gradually decreased to 0.641 +/- 2.7% BW 48 hours later. Lung compliance measured at the same time showed the lowest level 6 hours after the operation. It was known that the bioimpedance spectrum analysis is a simple and non-invasive method, which enables to monitor the vital stable before and after the operation.

We report a rare case of lung cancer associated with the right aortic arch. A 72-year-old male was admitted to our hospital for surgical treatment of squamous cell carcinoma arising from left B3. The patient had a right aortic arch with the type of mirror-image branching. He underwent a left upper lobectomy and lymph node dissection. We easily resected the lymph nodes in the left side of the upper mediastinum without rotating aortic arch because the aortic arch was positioned on the other side.

A 78-year-old woman was admitted to our hospital after computed tomography (CT) had revealed in her the presence of a giant ascending aorta-arch aneurysm. This aneurysm was about 8 cm in diameter and associated with DeBakey type II dissection. Aortography showed the same condition as the CT view with the entry on the ascending aorta. The ascending aortaarch was replaced with a Hemashield 24 mm, by using deep-hypothermic selective cerebral perfusion and the open distal method. There were no complications during her peripostoperative state and no evidence of leakage and remnant dissection on CT and aortography. This is a rare case in which thoracic aortic aneurysm coexisted with dissection. In this case of severe atherosclerosis, deep-hypothermic selective cerebral perfusion and the open distal method provided effective treatment.

An emergency coronary artery bypass graft (CABG) was given to a 66 year-old patient due to acute myocardial infarction (AMI). Circulating blood volume (BV) was measured to study in the perioperative period. Three coronary artery bypasses were made under cardiopulmonary bypass, being managed by ultrafiltration when the pump-oxygenator was in action and by peritoneal dialysis in the early postoperative period. Preoperative BV reduced immediately after the operation. It showed an increasing trend 4 hours after the operation, but after that BV reduced from that before the operation while water balance was kept positive. Cardiac output after the operation was higher than before. It suggested that in this patient using hemodialysis BV levels turned to be lower compared with that before the operation, as excessive water leaked out of the blood vessel, although water balance was kept positive due to improved cardiac functions after the operation.

A 16-year-old boy was diagnosed as having severe aortic regurgitation and moderate aortic stenosis due to congenital aortic bicuspid valve. A chest X-ray film showed the cardiothoracic ratio (CTR) of 64% and echocardiography revealed severe dilation of the left ventricular dimension with severe wall thickness. An electrocardiogram showed multiple ventricular arrhythmias. The patient underwent the Ross operation with the reconstruction between the right ventricle and the pulmonary arteries using a three-valved conduit which was made by an expanded polytetrafuloroethylene vessel graft. Ventricular arrhythmia disappeared just after the operation and left ventricular dimensions improved with the CTR of 53% except mild regurgitation of the neo-aortic valve three months later.

To investigate that blood transfusion under cardiopulmonary bypass is a possible inducer for inflammation, a retrospective study was made with 20 adult patients who underwent coronary artery bypass grafting. The subjects were divided into two groups; transfusion group (group T) including 9 patients who received blood transfusion during cardiopulmonary bypass and the control group (group C) including 11 patients who did not undergo perioperative transfusion. Respiratory index as an indicator of respiratory functions was determined before and immediately after cardiopulmonary bypass, at the end of surgery and 4 hours thereafter. Cardiac index and arterial pressure were determined as the indicator of cardiac function. Moreover, interleukin 6 and 8 (IL-6 and IL-8), inflammatory cytokines were measured and compared between the two groups. The mean amount of blood transfusion was 2.1 units per individual of group T. The minimum value of hematocrit during cardiopulmonary bypass was significantly lower in group T (15.8 +/- 1.8%) than group C (19.1 +/- 1.4%), but the difference became not significant after cardiopulmonary bypass. There were no significant differences either in aortic pressure or cardiac index between two groups. The respiratory index at the end of surgery was higher in group T but the difference was not significant. Meanwhile IL-8 level at the end of cardiopulmonary bypass was significantly higher in group T (67.9 +/- 36 pg/ml) than group C (35.1 +/- 21 pg/ml). However, there was no difference in IL-6 level between the two. These results suggested that inflammation might be aggravated by an increase of IL-8 induced by blood transfusion.

Seven patients with pulmonary carcinoid including three with typical carcinoid and four with atypical carcinoid were reported. There were 3 males and 4 females, with an age range of 37 to 80 years. All patients with typical carcinoid had pathological stage I. Of the patients with atypical carcinoid, one patient had stage I, two stage IIIA and one stage IIIB. All but two patients underwent lobectomy and mediastinal lymph node dissection. Bronchoplastic operation or right pneumonectomy were performed in the two patients. All but one patient underwent absolute or relative curative operation. Only one patient died on the 4th postoperative day. One patient with atypical carcinoid died of cancer recurrence 4 years after surgery. One patient died of breast cancer. One patient underwent surgery for metachronous multiple lung cancer, and he is doing well without recurrence. In conclusion, a limited operation is thought to be acceptable only in patients with typical carcinoid in a peripheral lesion without lymph node metastasis. Lobectomy and mediastinal lymph node dissection is necessary for the atypical carcinoid case.

We report a case of 59-year-old man of descending necrotizing mediastinitis (DNM) secondary to peritonsillar abscess. A 59-year-old man with diabetes mellitus was admitted to a local hospital because of cervical swelling related to a peritonsillar abscess. Despite administration of antibiotics, swelling of the neck, dysphagia and dyspnea deteriorated. Therefore he was urgently undergone a tracheotomy and transferred to our hospital by an ambulance. The surgery consisted with neck and anterior mediastinal drainage through neck and cervical collar incision. Culture of drainage fluid showed clostridium difficile. On postoperative day 5, we started hyperbaric oxygen therapy (HBOT). After lavage and HBOT, the patient improved by degrees, and discharged on postoperative day 82. DNM is a rare but serious complication of otopharyngeal and deep neck infection that spreads down to the mediastinum through the cervical-facial planes. Its mortality rate remains high even with aggressive surgical drainage and appropriate antibiotics. Our patient was successfully treated with urgent surgical drainage, antibiotics and HBOT. HBOT might be of great value as an adjunctive management to control this fatal infection.

A 62-year-old man with synchronous multiple primary cancers involving the lung, stomach, and thyroid was admitted. Initially the patient's chest X-ray showed an abnormal shadow in the right middle-lobe indicating lung cancer. During preoperative examination, gastric cancer of the antrum and angle were detected. Excisional biopsy of the lymph node in the neck after chest surgery revealed thyroid cancer. A middle lobectomy with mediastinal lymph node dissection was performed for lung cancer and the histological diagnosis was moderately differentiated adenocarcinoma, pT4N2M0, stage IIIB. Gastric cancer was treated by endoscopic mucosal resection. Considering the relatively better prognosis of papillary thyroid cancer, we concluded that no further treatment to the thyroid lesion was necessary. In Japan, according to autopsy reports, triple primary cancers are gradually increasing. During the periods 1994 to 1996, the incidence of triple cancers was 0.81% of all autopsy cases reported.

A 74-year-old man had an previous antero-septal and inferior myocardial infarction and an abdominal aortic aneurysm (AAA) 48 mm in diameter. Coronary angiography showed obstruction of the left anterior descending artery and of the right coronary artery, and 95% stenosis of the circumflex artery. The value of an ejection fraction of the left ventricle was 33%, measured by left venticulography. CABG and replacement of the aneurysm were performed simultaneously, because of the necessity of an intra-aortic balloon pumping (IABP) due to the impaired left ventricular function. First, CABG was performed under cardiac arrest. After declamping the ascending aorta, subsequently, replacement of AAA was performed while extracorporeal circulation (ECC) assisted heart beating. Weaning from ECC was smooth, and the operation was successful without using IABP. The patient was discharged 32 days after the operation. Consequently, cardiopulmonary bypass during AAA operation could decrease heart loads when hemodynamic states change in aortic clamping or after declamping. A simultaneous operation of CABG and AAA using ECC is safe and effective for impaired left ventricular function.

A 42-year-old man with giant bronchogenic cyst occupied from the middle and posterior mediastinum was treated surgically. The tumor was stoutly adhered to anterior aspect of the esophagus and membranous portion of the right bronchus. In dissecting the tumor, muscular coat of the esophagus was partly severed, which was repaired interruptedly with absorbable suture material. However, esophageal perforation was detected by barium swallow on the 3rd postoperative day. Conservative therapy included intrathoracic drainage and antibiotics was successfully undertaken. It is imperative to dissect the tumor very carefully if the giant bronchogenic cyst adheres to the esophagus or other surrounding organs.

We presented a 66-year-old man with synchronous double cancers developing in the right upper lobe, which were diagnosed preoperatively. He underwent right upper lobectomy with hilar and mediastinal lymphadenectomy. Post-operative patho-histological study showed two different histologic types of cancer; one was undifferentiated carcinoma of the small cell type, and the other was moderately differentiated adenocarcinoma.

Chondrosarcoma originating in the rib is a rare disease. Although its pathological characteristics are believed to be mild, it is apt to recur and prognosis deteriorates in the absence of appropriate excision. The authors experienced a patient with a chondrosarcoma in the right 6th rib. The patient was a 49-year-old man who visited our hospital with a mass in the right anterior chest wall and chest pain. The patient underwent radical excision of the bony chest wall including the right 5th to 7th ribs. The resulting defect in the chest wall was restored with double-overlapping Marlex mesh. There has been no sign of recurrence to date, 6 years and 1 month postoperatively.

Cor triatriatum associated with situs inversus is rare. A 6-month-old male who had cor triatriatum with atrial septal defect (ASD) and situs inversus totalis was successfully operated. Urgent surgical intervention was performed because of congestive cardiac failure despite drug therapy. The abnormal septum in the left atrium was resected and ASD was closed. His postoperative course has been uneventful.

A 46-year-old female with mitral insufficiency complicated by hereditary hemorrhagic telangiectasia (Osler's disease) underwent successfully mitral valve replacement. The patient had a history of repeated large-volume nasal bleeding. Mitral valve replacement using a xenograft was safely performed with various attempts for preventing abnormal postoperative hemorrhage.

A simple and inexpensive sternal splint for delayed sternal closure was described. Sternal edges were splinted open using an edge-cut disposable syringe. This method has been employed successfully in 10 patients (one adult, 9 children). This syringe splint is a simple, inexpensive and effective method for delayed sternal closure.

This report describes two cases of aortic valve replacement which was warranted by the suddenly developed aortic regurgitation due to a congenitally bicuspid aortic valve. Aortic insufficiency was caused by the rupture of the strand which lifted a larger cusp to the aortic wall in one, and by the perforation of valvular aneurysm in another. Reviewing the literature these types of aortic insufficiency are rarely reported.

A 54-year-old man suddenly felt a strike on his chest while mowing with a machine. At first he had no symptoms except for wound pain, but several hours later, he suffered from high fever with chilliness. The chest roentgenogram showed a foreign body localized within the cardiac shadow. The echocardiogram revealed that the metallic fragment was embedded in the inferior wall of the left ventricle. It appeared that the fragment entered the left ventricular cavity through his anterior chest wall, the right ventricular outflow tract and the ventricular septum. At the operation, the location of the foreign body was again confirmed by the intraoperative echocardiography and the fragment was successfully removed through a left ventricular incision under cardiopulmonary bypass. The postoperative course was uneventful and the case was reported with a review of the literature.

A 42-year-old house wife had suffered from abnormal mass lesion in the right pulmonary hilum on her chest X-ray film. MRI showed another mediastinal mass between IVC and descending aorta with high T1 and T2 intensity. Thoracic CT done before MRI missed the latter lesion because only upper mediastinal scanning had been performed. At operation subcarinal and right paraesophageal cysts were successfully removed. Histological examination of the subcarinal cyst showed ciliated pseudostratified columnar epithelium lining, and its thin wall consisted of partly smooth muscle bundle, lymph node, calcification, inflammatory cell infiltration and hemorrhage. The paraesophageal cyst lined by a ciliated pseudostratified columnar epithelium, and the wall consisted of mostly fibrous connective tissue with partly smooth muscle bundle. Although the both cysts were diagnosed as bronchogenic origin, definitive bronchial glands and cartilage could not be recognized. The postoperative course was uneventful. This is the first case report of mediastinal double bronchogenic cysts appeared in the Japanese literature.

This is a case report of a 61-year-old man, suffering from infective endocarditis of mitral valve in association with DIC and intracerebral hemorrhage. He was treated symptomatically and conservatively for 80 days after the onset of the DIC. His multiple cerebral hematomas gradually disappeared 2 months after conservative management. Then the diseased mitral valve was replaced with a Duromedics valve. He is doing well at present. In a review of the literature it appears that there is some room for surgical intervention in endocarditis despite the complication of coagulopathy. We feel that one of the most serious complications of infective endocarditis is DIC. Operative management of endocarditis with this complication is recommended to be followed by medical management.

The newly developed oxygenator "D702" is a compact hollow fiber membrane oxygenator with a priming volume of 170 ml. The maximum flow allowance is 4 liters per/minute. We used this oxygenator in 16 patients (11 infants and children, and 5 adults) undergoing various open heart surgery, and function of this oxygenator was studied. Pulsatile cardiopulmonary bypass was performed in 8 patients and nonpulsatile constant flow perfusion was employed in the remaining 8 patients. Our clinical experience showed excellent maintenance of PaO2 and PaCO2 during both pulsatile and constant flow bypasses. A low pressure drop was encountered across the membrane oxygenator, and therefore, this oxygenator is applicable for pulsatile cardiopulmonary bypass. The D702 is a very useful and applicable for a wide range of patients from infants to adults with a small body structure.

A 36-year-old housewife, who had been treated with hemodialysis for 15 years is reported. She had suffered from active infective endocarditis of the aortic valve caused by blood access infection for several weeks. She rapidly fell into severe cardiac failure. Five days after the onset of the cardiac failure she was transferred to our hospital. The aortic valve was replaced using #21 Björk-Shiley aortic valve prosthesis shortly after the arrival to the hospital. Postoperatively she was treated with vigorous antibiotics and was anticoagulated. Seven months after the surgery, patient is back to an active life with hemodialysis 3 times a week.

This is a case report of the successful surgical treatment of acute dissecting aneurysm of the ascending aorta. The patient was a 65-year-old female, who admitted to the hospital 3 hours after the onset of severe back pain. Enhanced CT of the chest and abdomen revealed acute dissection of the ascending aorta from its origin to the bilateral common iliac arteries. Thirteen hours initiation of the symptoms, operation was carried out using pump-oxygenator with hypothermia. Transverse incision of the ascending aorta revealed acute dissection in anterior aspect extending to two third of the circumference. The proximal small intimal tear was found 3 mm apart from the right coronary artery ostium. Upon closure of the tear resulting in obliteration of the right coronary artery, it required bypass procedure between the right coronary artery and the innominate artery using the saphenous vein graft. The aortic incision was directly closed using Dacron felt bolsters. Postoperative studies revealed disappearance of the proximal aortic dissection, patency of the bypass graft and existence of distal aortic dissection. Patient is in active life 6 months after operation.

A 5-year-old girl with multiple pulmonary arterio-venous fistulae was reported. Both her mother and grandmother have been diagnosed as the same disease previously. Her grandmother was treated with resection of the right basal segment for arterio-venous fistulae. Her mother is well with fistulae for more than 20 years. The patient was operated upon to enucleate two larger fistulae in segments 3 and 6 of right lung. Her postoperative course was uneventful. She was discharged from the hospital on the 22nd postoperative day. Pulmonary arteriovenous fistulae are thought to be a part of the hereditary hemorrhagic telangiectasis. Enucleation of the larger fistulae of the lung are preferable even for multiple lesions.