Guillain–Barré syndrome after cardiac surgery: diagnostic dilemma Abstract Guillain–Barré Syndrome after cardiac surgery is very uncommon. Mechanism remains elusive although immunological reaction post surgery has been postulated. This disease can potentially increase the morbidity of the postoperative patients and generally cannot be explained by the cardiac disease or interventions. It is very much essential to diagnose the condition as appropriate management can substantially and profoundly change the course of treatment.

The preoperative assessment of subpleural lung cancer movement to distinguish thoracic wall adhesion or invasion using four-dimensional computed-tomography Abstract Four-dimensional computed tomography (4DCT) is a relatively new technology. A review of the relevant medical literature reveals only very limited previous investigations of the utility of this technique. We report two cases of lung cancer located adjacent to the pleura in which 4DCT was used to assess parietal pleural invasion or adhesion based on the differential movements of tumors. We performed 4DCT to determine the surgical approach after obtaining appropriate informed consent from the patient. Based on 4DCT, Patient 1 showed there was no adhesion and we could perform thoracoscopic right lower lobectomy and the final pathological diagnosis was pT1bN0M0. Patient 2 Based on 4DCT, showed suspicious of invasion or adhesion. we performed chest wall resection because of tumor invasion in the eighth and ninth costal bones; a final pathological diagnosis of pT3N0M0 was made.

A rare resected case of pulmonary rhabdomyosarcoma Abstract Rhabdomyosarcoma is a well-known neoplasm in children that frequently occurs in the extremities, the head and neck region, and the genitourinary tract. To the best of our knowledge, pulmonary primary rhabdomyosarcoma in adults is exceedingly rare, and few resected cases have been reported. We report a case of pulmonary primary rhabdomyosarcoma that was surgically resected then treated with adjuvant chemotherapy (vincristine, actinomycin-D and cyclophosphamide). At 9 months after surgery, the patient is free from disease. Although the prognosis of rhabdomyosarcoma is unfavorable, surgical resection and adjuvant therapy could be a potential treatment strategy for pulmonary primary rhabdomyosarcoma.

Acknowledgment to reviewers

Solitary peribronchiolar metaplasia showing a sub-solid nodule on computed tomography Abstract Recent advances in radiographic imaging and thoracic surgery have facilitated surgery for small lung tumors by eliminating the need for pathological diagnosis. To date, we have experienced two cases of small lung tumors that were surgically resected without pathological diagnosis as malignant. Computed tomography (CT) revealed sub-solid nodules in the peripheral lung. After tumor resection, both tumors were pathologically diagnosed as peribronchiolar metaplasia. To the best of our knowledge, solitary peribronchiolar metaplasia showing a sub-solid nodule on CT imaging has not previously been reported.

Successful hybrid treatment of a rare case of blunt traumatic rupture of the left atrial basal appendage and aortic arch Abstract Despite advances in emergency care and the emergent transportation system, cardiac and aortic ruptures after blunt trauma are associated with high mortality and morbidity. We present a rare case of a 70-year-old man with a ruptured left atrial basal appendage and distal aortic arch after sustaining blunt trauma to the chest during a motor vehicle accident. The patient was transported to our hospital in a state of shock and taken directly to the operating room. Hybrid treatment was performed, including surgical repair of the left atrium under cardiopulmonary bypass and thoracic endovascular aortic repair, was performed. The patient fully recovered without any complications.

Tiny ruptured coronary aneurysm with coronary-pulmonary arterial fistula Abstract A 44-year-old man was admitted to our hospital with chest pain. We diagnosed him with pericardial effusion collection because of a spontaneous ruptured coronary aneurysm of 1.5 cm with coronary pulmonary arterial fistula (CPAF) by enhanced computed tomography and angiography. We completely resected the ruptured aneurysm and safely closed the CPAF. Rupture of coronary aneurysms with CPAF is rare, especially tiny aneurysms. In previous reports, most cases were older women and the diameter of the ruptured aneurysms was greater than 3.0 cm. We report a case of a middle-aged man with a tiny ruptured coronary aneurysm with CPAF.

Usefulness of intraoperative nerve monitoring in esophageal cancer surgery in predicting recurrent laryngeal nerve palsy and its severity Abstract Background Recurrent laryngeal nerve (RLN) palsy is a critical postoperative complication in esophageal cancer surgery. However, intraoperative prediction of its occurrence and severity is difficult. In this prospective study, we evaluated the usefulness of intraoperative nerve monitoring (IONM) in predicting RLN palsy and its severity. Methods Twenty patients who underwent subtotal esophagectomy with 3-field lymph node dissection were enrolled. Intraoperative electromyography (EMG) amplitudes of the vocal cords were measured by IONM at RLN and vagus nerve (VN) stimulation. Comparison was made between the vocal cords with RLN palsy and those without palsy and additionally between the vocal cords with transient RLN palsy and those with persistent palsy. Results Among 40 vocal cords in 20 patients, 26 were intact and 14 were paralyzed. Seven had transient, six had permanent palsy. The mean EMG amplitude of intact vocal cords was significantly larger than that of paralyzed ones at VN (506 ± 498 µV vs. 258 ± 226 µV, p = 0.022) and RLN stimulation (642 ± 530 µV vs. 400 ± 308 µV, p = 0.038). The cut-off value for postoperative palsy were 419 µV [positive predictive value (PPV): 48.0%, negative predictive value (NPV): 84.6%] at VN and 673 µV (PPV: 44.8%, NPV: 90.9%) at RLN stimulation. The mean EMG amplitude of persistently paralyzed vocal cords tended to be small, compared with that of recovered ones at both VN (168 ± 173 µV vs. 336 ± 266 µV, p = 0.11) and RLN (244 ± 223 µV vs. 536 ± 344 µV, p = 0.051) stimulation. Conclusion The absolute EMG amplitude of IONM might be helpful to predict the occurrence and severity of RLN palsy after esophageal surgery although the predictive value is low.

Early outcomes of transcatheter aortic valve implantation for degenerated aortic bioprostheses in Japanese patients: insights from the AORTIC VIV study Abstract Objective The valve-in-valve procedure, in which a transcatheter heart valve (THV) is implanted into a degenerated bioprosthetic valve, is standardized for high-risk patients. However, this procedure is challenging in Japanese patients who have a small aortic annulus. We investigated the feasibility, safety, and therapeutic efficacy of the valve-in-valve procedure involving a degenerated stented bioprosthesis, stentless bioprosthesis, or THV. Methods We performed a single-center, non-comparative study of the aortic valve-in-valve procedure (AORTIC VIV study). Beginning in October 2016, the aortic valve-in-valve procedure was performed in seven patients with a stented bioprosthesis, in three patients with a stentless bioprosthesis, and in one patient with a THV. Results No 30-day post-procedure mortality or severe morbidities occurred. The mean echocardiographic gradient in the aortic position improved from 41 (38–48) to 17 (11–22) mmHg at 30 days (p = 0.01). No paravalvular or mild and more transvalvular leaks were detected. The New York Heart Association functional class improved from 2 (2–2.5) to 1 (1–1) at 30 days postoperatively (p = 0.01). Although the procedure failed in two patients with an implanted stentless bioprosthesis, the third patient with a stentless bioprosthesis and the one patient with a degenerated THV successfully underwent the valve-in-valve procedure. Conclusions Feasibility, safety, and potential efficacy of the aortic valve-in-valve procedure were confirmed in selected Japanese patients with a degenerated aortic bioprosthesis. The valve-in-valve procedure for stentless bioprostheses was technically challenging.

Quality assessment using EQ-5D-5L after lung surgery for non-small cell lung cancer (NSCLC) patients Abstract Objectives Aim of this study was to elucidate an alteration of quality of life (QOL) score before and after video-assisted thoracoscopic surgery (VATS) for non-small cell lung cancer (NSCLC) patients using the 5-level EuroQol-5D questionnaire (EQ-5D-5L). We also investigated how the preoperative QOL scores affected the postoperative clinical outcome prospectively. Methods Between July 2018 and December 2018, 24 consecutive NSCLC patients who underwent VATS were recruited. The EQ-5D-5L for Japanese was used with face-to-face interviews to estimate the utility values of QOL. Results QOL scores were significantly declined after surgery (0.81 ± 0.19 vs. 0.74 ± 0.11: P = 0.049). The levels of EQ-5D-5L questionnaire were not significantly different before and after surgery except Q4 (pain control). The levels of Q4 were significantly worsened after surgery (1.33 ± 0.56 vs. 1.88 ± 0.61, P < 0.001). Operation time and bleeding in the preoperative low-QOL score group (N = 13) was longer (215.4 ± 52.3 min. vs. 173.5 ± 42.3 min., respectively: P = 0.045) and more (116.2 ± 152.7 ml vs. 22.7 ± 20.1 ml, respectively: P = 0.049) than those in the high-QOL score group (N = 11). Conclusions QOL survey for lung cancer patients using EQ-5D-5L is simple and useful to identify the issue facing at the medical team. Preoperative low QOL score could be a predicting factor for the longer operation time and more bleeding.