• Journal of Chest Surgery
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• v.35 no.3
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• pp.217-222
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• 2002

Background: The incidence of gastroesophageal reflux disease(GERD) is increasing recently, but medical management for GERD has many limitations. Therefore, variable surgical treatments have been introduced. Material and Method: A retrospective study was done in 10 patients who underwent the Belsey Mark IV operation at Korea university Guro hospital between 1996 and 2001. Preoperative diagnoses were hiatal hernia with gasroesophageal reflux in 8 patients and achalasia in 2 patients. Result: Mean age of the patients was 54.3$\pm$19.0 years. Belsey Mark IV operation was performed on patients where preoperative medical failed and mean hospital days were 13.1$\pm$2.6 days. We routinely practiced follow-up endoscopy on postoperative 3rd, 6th, 9th, and 12th months. After remission for reflux and esophagitis, they were transferred to internal medicine department. Six patients of hiatal hernia with reflux (one patient who lost follow-up and the other patient who didn't practice the follow-up endoscopy due to short postoperative follow-up period were excluded) had lowered endoscopic gradings and two patients of achalasia did not complained of reflux symptoms, postoperatively. We experienced 10% operation failure rate. Conclusion: We experienced satisfactory operation results with Belsey Mark IV in hiatal hernia with GERD and achalasia patients.

• Journal of Chest Surgery
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• v.30 no.8
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• pp.752-759
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• 1997

Profound hypothermia protects . cerebral function during total circulatory arrest(TCA) in the surgical treatment of a variety of cardiac and aortic diseases. Despite its importance, there is no ideal technique to monitor the brain injury from ischemia. Since 1994, we have developed compressed spectral array(CSA) of electroencephalography(EEG) and monitored cerebral activity to reduce ischemic injury. The purposes of this study are to analyse the efficacy of CSA and to establish objective criteria to consistently identify the safe level of temperature and arrest time. We studied 6 patients with aortic dissection(AD, n=3) or aortic arch aneurysm(n=3, ruptured in 2). Body temperatures from rectum and esophagus and the EEG were monitored continuously during cooling and rewarming period. TCA with cerebral ischemia was performed in 3 patients and TCA with selective cerebral perfusion was performed in 3 patients. Total ischemic time was 30, 36 and 56 minutes respectively for TCA group and selective perfusion time was 41, 56 and 92 minutes respectively for selective perfusion group. The rectal temperatures for flat EEG were between 16.1 and 22. $1^{\circ}C$ (mean: 18.4 $\pm$ 2.0): the esophageal temperatures between 12.7 and $16.4^{\circ}C$ (mean $14.7\pm1.6).$ The temperatures at which EEG reappeared $5~15.4^{\circ}C$ for esophagus. There was no neurological defic t and no surgical mortality in this series. In summary, the electrical cerebral activity Teappeared within 23 minutes at the temperature less than $16^{\circ}C$ for rectum. It seemed that $15^{\circ}C$ of esophageal temperature was not safe for 20 minutes of TCA and continuous monitoring the EEG with CSA to identify the electrocerebral silence was useful.

• Journal of Chest Surgery
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• v.30 no.11
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• pp.1062-1068
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• 1997

From August 1989 to January 1996, a total of 105 cases of bidirectional Glean operations have been done as the interim stage for the patien s with some risk of univentricular correction at Sejong General Hospital. From December 1992, we started the conversion to Fontal operations for them, and 42 cases underwent Fontal-stage operation till February 1996. Their diagnoses were univentricular heart in 19(right ventricular type : 14), tricuspid atresia 11, double outlet of right ventricle 9, and others in 3 cases. The median age of bidirectional Glerln-stage operation was 12.5 months(range 2 months to 8 years) and Fontan-stage operation was at 59.6 months of median age(range 1 year 5 months to ,9 year 7 months). The mean waiting interval between the two operations was 33.88 $\pm$ 17.85 months with a range of 10 months to 6 years 3 months. During the waiting periods, 18 patients developed significant systemic-pulmonary collaterals andfor systemic verso-veno collateral channels. There were 5 hospital deaths after operations due to low cardiac output in 4 and sepsis in one. Most of the Fontal-stage operations were done by the late al tunneling with Core-Tex tube graft patch and fenestrated with the size of 2.5 ~6 mm. All the patients were followed-up(7 months to 4 years 2 months, mean 21.97$\pm$10.82 months) and there were 5 late deaths(postoperatively 6 months to 2 years) due to thromboembolism in 1, after heart transplantation 1, plastic bronchitis 1, protein loosing enteropathy 1, and pneumonia in 1. Dividing the patients by the waiting interval of 2 years, the early correction to Fontal group (N=16) showed the better results(hospital mortality 1116, late mortality 1116, significant collateral development 2/16) compared to the other group(N=26) (4/26, 4/26, 16/26). In conclusion, after the bidirectional Glean-stage operation successfully got rid of the previous risk factors, we recommand to do the Fontan-stage operation no later than 2 years of interval.

• Journal of Chest Surgery
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• v.35 no.3
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• pp.177-181
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• 2002

Background: Follow-up studies have shown that although outcomes have improved substantially over time, results of the Fontan operation and its modifications remain suboptimal. In this study, we reviewed our experience with the extracardiac conduit Fontan operation, with a focus early and midterm change of internal diameter of PTFE conduit. Material and Method: Between April 1997 and July 2000 were reviewed. Twelve patients (M:6, F:6, mean age 42.04 $\pm$ 12.43months, mean body weight 13.80$\pm$ 1.94kg) underwent extracardiac conduit Fontan operation with expanded PTFE graft. Mean cardiopulmonary bypass time was 109.7$\pm$26.99minute and mean operation time was 455$\pm$89.51minute. Intraoperative fenestration was performed in 10 patients. The aortic cross clamping was not performed in all patients. Result: There was no early deaths and no postoperative dysrhythmia. Postoperative protein losing enteropathy and prolonged pleural effusion occurred in 1(8.3%) and 4 patients(33.3%). Conduit patency was evaluated by magnetic resonance imaging studies. A 9.84$\pm$3.84% mean reduction in conduit internal diameter and there was no statistical correlation between the change of internal diameter of conduit and the postoperative duration after partial correlation analysis(r=0.019, p=0.955). Conclusion: These results demonstrate that the extracardiac conduit Fontan operation provies good early and midterm results and may reduce the prevalence of late arrhythmia. And there is no correlation between the change of internal diameter of conduit and the postoperative duration after extracardiac conduit Fontan operation with the expanded PTFE graft conduit.

• Journal of Chest Surgery
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• v.29 no.6
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• pp.593-598
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• 1996

The large number of past investigation on extended myocardial protection clearly indicates that cold potassium cardioplegia and topical cooling have limited capabilities. Accordingly, more recent experimen- tal approaches have focused on the modalities of reperfusion and their implication on postischemic myo- cardial recovery. Oxygen may play a crucial role in the development of ischemic and reperfusion injury. Reactive oxygen radicals may be produced during ischemia or reperfusion after incomplete reduction of molecular oxygen or from other pathway and then induce fatal injury of the heart. The important obser- vation of oxygen-induced myocardial damage during reperfusion has led to the concept of applying oxy- gen free radical scavengers. So, this study is on dietary vitamin C supplementation as antioxidant in rats to determine whether or not they have a higher tolerance against cardiac ischemia-reperf'usion injury under Langendorff system. Male or female Sprague-Dawley rats (190-33Og) were randomly separated into two groups. Group A was not treated(n=10). Group B received vitamin C supplement (n=10). Experiment was performed 24 hours after vitamin C 200mg fed orally as injectable ascorbic acid. There were significant differences in contractile parameters between control and vitamin C-treated group. The RLVP (r te of post/preischemic left ventricular pressure) and Rdp/dt (rate of post/preischemic dp/dt) were significant statistically between two groups (p<0.05). But, RHR (rate of post/preischemic heart rate), time to first beat and sta'utilization were not significant. In conclusion, pretreatment with the antioxidant, ascorbic acid, was found to preserve left ventricular contractile function. But the precise mechanism of action of ascorbic acid has not as yet been determined, so further study will be required.

• Journal of Chest Surgery
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• v.36 no.5
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• pp.321-328
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• 2003

Background: The St. Jude Medical prosthesis is one of the popularly used artificial prosthesis, therefore the National Medical Center reports the long-term clinical results of patients who underwent prosthetic valve replacement with St. Jude medical valve for 18 years. Material and Method: Between January, 1984 and June, 2002, a series of 163 consecutive patients who had Implanted St. Jude prosthesis at the National Medical Center were reviewed. Mean age was 42.9$\pm$15.1 years and male to female ratio was 69:94. The operative procedure comprised of 87 MVR, 30 AVR, 45 DVR, and 1 TVR. The reoperative procedure comprised of 21 MVR, 2 AVR, and 14 DVR. Follow-up rate was 96.9%, and cumulative follow-up was 823.8 patient-years. Result: Early mortality rate was 7.9% (13 patients), late mortality rate was 8.7% (13 patients) and late mortality due to valve related complication was 47% (7 patients). Actual survival rate at 10 and 18 years were 91.7$\pm$2.1% and 91.0$\pm$1.9%. Linearized Incidence was as follows: thromboembolism, 1.09%/ patient-year; anticoagulant related hemorrhage, 0.36%/patient-year; valve thrombosis, 0.24%/patient-year; paravalvular leakage, 0.12%/patient-year; and prosthetic bacterial endocarditis, 0.12%/patient-year linearized incidence of over all valve related complication was 1.94%/patient-year. Freedom from valve related complication at 10 and 18 years were 89.1$\pm$3.3% and 88.4$\pm$3.9%. Freedom from valve related death at 10 and 18 years were 95.1$\pm$1.2% and 95.1$\pm$1.0%. Valve related complication was related the age of patient, especially anticoagulant related hemorrhage was more common in patients over 60 years of age. Valve related complication, death were higher in DVR than AVR or MVR, and valve related death was higher in reoperation. There was no relationship between valve related complication or death and implant valve of size. Conclusion: The long-term clinical results of patients implanted with St. Jude Mechanical prosthesis was quite satisfactory with a low incidence of valve related complication and mortality.

• Journal of Chest Surgery
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• v.36 no.5
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• pp.348-355
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• 2003

Background: The prognostic significance of lymph node micrometastasis in non-small cell lung cancer remains controversial. We therefore investigated the clinicopathologic factors related to lymph node micrometastsis and evaluated the clinical relevance of micrometastasis with regard to recurrence. Material and Method: Five hundred six lymph nodes were obtained from 41 patients with stage 1 non-small ceil lung cancer who underwent curative resection between 1994 and 1998. Immunohistochemical staining using anti-cytokeratin Ab was used to detect micrometastasis in these lymph nodes. Result: Micrometastatic tumor cells were identified in pN0 lymph nodes in 14 (34.1%) of 41 patients. The presence of lymph node micrometastasis was not related to any clinicopathoiogic factor (p) 0.05). The recurrence rate was higher in patients with micrometastasis (57.1%) than in those without (37.0%), but the difference was not significant (p=0.22). Patients with micrometastasis had a lower 5-year recurrence-free survival rate (48.2%) than those without micrometastasis (64.1%), with a borderline significance (p=0.11), The S-year recurrence-free survival rate (25.0%) in the patients with 2 or more micrometastatic lymph nodes was significantly lower than that in the patients with no or single micrometastasis (p=0.02). In multivariate analysis, multiple lymph node micromestasis us was a significant independent predictor of recurrence (p=0.028, Risk ratio=3.568). Conclusion: Immunehistochemical anti-cytokeratin staining was a rapid, sensitive, and easy way of detecting lymph node micrometastasis. The presence of lymph node micrometastasis was not significantly associated with the recurrence, but had a tendency toward a poor prognosis in stage 1 non-small cell lung cancer. Especially, the presence of multiple micrometastatic lymph nodes was a significant and independent predictor of recurrence.

• Journal of Chest Surgery
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• v.36 no.11
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• pp.799-811
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• 2003

Background: The aim of this study is to define the cardioprotective effects (hemodynamic, cytochemical and ultrastructural of the newly developed Histidine-Tryptophan-Ketoglutarate (HTK) cardioplegia compared to DelNido cardioplegia. Material and Method: Seventy-nine isolated rat hearts were divided into three groups on the basis of techniques of cardioplegia infusion. Twenty-eight hearts (Group 1) were flushed with cold DelNido cardioplegia with every 40 minutes for 2 hours. Twenty-seven hearts (Group 2) were flushed with cold HTK cardioplegia for once during the 2 hours. Twenty-four hearts (Group 3) were flushed with cold HTK cardioplegia with every 40 minutes for 2 hours. Heart rate, left ventricular developed pressure (LVDP), changes of + dp/dt max, coronary flow, and rate-pressure product value were measured at pre-ischemic, post-reperfusion 15 minutes, 30 minutes, and 45 minutes for hemodynamic study. Aspartate aminotransferase (AST), lactate dehydrogenase (LD), creatine kinase (CK), CK-MB, troponin-I, myoglobin, and lactate were measured at pre-ischemic and post-reperfusion 45 minutes for cytochemical parameters. Mitochondrial scores were counted in 3 cases from each group for ultrastructural assessment. Result: In hemodynamic study, there were no significant differences among group 1, group 2, and group 3. However, the decrease values of heart rate in group 2 and 3 exhibited significantly lower values than in group 1. In cytochemical study, there were no significant differences among group 1, group 2, and group 3. However, the increase values of lactate in group 2 and 3 exhibited significantly lower values than in group 1. In ultrastructural assessment, the mean myocardial mitochondria scores in group 1, group 2, and group 3 were 2.14$\pm$0.10, 1.52$\pm$0.57, and 2.10$\pm$0.16. Conclusion: HTK solution provides adequate myocardial protection with some advantages over DelNido solution in isolated rat hearts.

• Journal of Chest Surgery
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• v.36 no.11
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• pp.846-851
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• 2003

Background: To clarify the clinical significance of the aortic nodes in resected non-small cell lung cancer of the left upper lobe. Material and Method: One hundred fifty six patients with resected non-small cell lung cancer of the left upper lobe were studied. Patients who received preoperative induction therapy, non-curative operation or defined as operative mortality were excluded from this study. Result: In N2 left upper lobe tumors, aortic nodes comprised 52.7% of the metastatic mediastinal lymph nodes. In single station N2 disease, a frequently metastasized station was aortic node (64.3%). 5-year actuarial survival according to the N status was 65.0% in N0, 30.4% in N1, and 17.9% in N2. There was no statistically significant difference in survival between N1 and N2 diseases (p=0.06). The patients with metastasis to aortic node alone had a comparatively good prognosis (5-year survival: 35.6%) than other N2 diseases (5-year survival: 4.6%) (p=0.01) and had a similar survival outcome as N1 diseases (p=0.97). Considering the aortic node as N1 node, 5-year survival according to the N status was 65.0% in N0, 31.2% in N1, 4.6% in N2 and significant survival difference was observed between N1 and N2 disease (p=0.00). In multivariate analysis, the male sex (hazard ratio 6.892, p=0.011) and the involvement to the aortic node alone (hazards ratio 2.799, p=0.009) were the significant factors affecting postoperative survival. Conclusion: According to the our data, involvement to the aortic node alone in left upper lobe tumors should be grouped with N1 disease because this combined category reflects the surgical outcome more accurately.

• Journal of Chest Surgery
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• v.31 no.9
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• pp.884-892
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• 1998

Background: The gastroepiploic artery is not only an alternative graft but also may be considered an important primary graft for coronary revascularization. However, the long-term patency of the gastroepiploic arterial graft is yet to be determined and the incidence of perioperative spasm and long-term patency of a coronary graft may be affected by the properties of the graft response to certain vasoactive substances. The reactivity of the gastroepiploic artery to vasoactive substances has not been studied extensively and the results of the studies are contradictory. Material and Method: This study was designed to test the reactivity of human gastroepiploic artery to four constrictors and four relaxants. The middle sections of the human gastroepiploic arteries were collected from the patients undergoing gastrectomy and the arterial rings with intact endothelium were suspended in organ baths for isometric tension recording. Result: Epinephrine, norepinephrine, and potassium chloride induced the maximum constriction to higher forces (7.0$\pm$1.1g, 6.6$\pm$0.9g, and 6.5$\pm$1.1g) than 5-hydroxytryptamine did (3.8$\pm$1.7g, p<0.05). Nitroprusside and histamine induced almost full relaxation in the gastroepiploic arteries preconstricted with norepinephrine. There was no significant difference between two relaxants regarding maximum relaxation force. Acetylcholine induced the maximum relaxation to weaker force when compared with nitroprusside and histamine (p<0.05), and isoproterenol was the weakest of the relaxants (p<0.05 compared with acetylcholine). Conclusion: The gastroepiploic artery has a strong capacity of endothelium-dependent relaxation which could have an important influence on long-term patency. The gastroepiploic artery exhibits a potent contractility to catecholamines and the enhanced contractility may facilitate vasospasm in the presence of high circulating levels of catecholamines. Nitroprusside, a potent relaxant in gastroepiploic artery, might be beneficial for the treatment of gastroepiploic arterial graft spasm. The gastroepiploic arterial graft with intact endothelium may respond weakly to beta-adrenoceptor agonist and 5-hydroxytryptamine.