Left Recurrent Nerve Palsy Research Articles

Chronic left pulmonary artery occlusion caused by a distal aortic arch aneurysm: Simultaneous Frozen Elephant Trunk and left sided pulmonary endarterectomy after livesaving TEVAR for aortic rupture

We present a case of a 62-year-old male patient with chronic distal aortic arch aneurysm causing recurrent nerve palsy and prolonged total occlusion of the left main pulmonary artery (PA). During diagnostic work up, the aneurysm ruptured requiring cardio-pulmonary resuscitation (CPR) and emergency retrograde stenting. After circulatory stabilization the patient was treated with controlled hypothermia for 24 h, and successive extubation without neurological deficit.Postinterventional imaging revealed a reversed perfusion of the aneurysmal sac through the PA, prompting open surgical treatment. Surgery consisted of reconstruction of the left PA by pulmonary endarterectomy (PEA), xenopericardial patchplasty of the left PA and frozen elephant trunk (FET) repair after removal of the bare springs of the previously inserted Gore Tag stent graft. Pre-discharge computed tomography angiography (CTA) demonstrated a fully recanalized left PA system and a completely excluded aneurysm. At ten-year follow-up the patient presented physically unimpaired (NYHA I). CTA confirmed a fully intact thoracic aorta and improved pulmonary function despite persisting left recurrent nerve palsy.

Left recurrent nerve lymph node dissection in robotic esophagectomy for esophageal cancer without esophageal traction

BackgroundBecause the robotic arm is located on the dorsal side of the patient, when the esophagus is pulled dorsally for the left recurrent nerve lymph node (LRLN) dissection, the robotic arm interferes with the surgical field. This made it difficult to prepare for the left recurrent lymph node dissection. We developed LRLN dissection in robotic surgery with natural space creation by physiological organ movement and evaluated the short-term results.MethodsIn this retrospective study, we analyzed 102 cases of robot-assisted thoracoscopic subtotal esophagectomy (RATE) among radical subtotal esophagectomies performed between December 2018 and December 2022 using medical records. LRLN dissection is preceded by a dissection of the esophagus from the trachea. Leaving the esophagus on the vertebral side and away from the trachea resulted in a physiological elevation of the esophagus, providing space between the trachea and esophagus.ResultsThe thoracic surgery time in RATE was 181 (115–394) min. The number of LRLNs dissected was 4 (1–14). Six patients (6%) had a postoperative recurrence in the mediastinal lymph nodes. Seven patients (7%) had grade ≥ 1 left recurrent nerve palsy.ConclusionsLRLN dissection with RATE using natural space creation was performed safely with a sufficient number of dissected lymph nodes and little left recurrent nerve palsy.

66 SHORT-TERM RESULTS OF RADICAL SURGERY FOR ESOPHAGEAL CANCER WITHOUT THORACOTOMY

Abstract In recent years, surgery without thoracotomy for esophageal cancer has been reported by performing mediastinoscope and laparoscope-assisted esophagectomy. It is reported that this procedure reduces pulmonary complications. Methods Since June 2018, we introduced this surgical operation for esophageal cancer patients using mediastinoscope without thoracotomy. The patient was placed in a supine position and tilts head slightly to the right with bilateral lung ventilation. The upper mediastinal dissection, using a left cervical approach, was performed with a single-port mediastinoscopic technique using LigaSure™ Maryland. But the lymph nodes along the right recurrent laryngeal nerve (RLN) were dissected under direct vision using a right cervical approach. And then, the operation and the course after the operation were examined. Results We experienced 14 cases of surgery by February 2020 and have experienced only one pulmonary complication in the course of the surgery. This case had a left recurrent nerve palsy as a complication after surgery. For this reason, aspiration was combined, but it improved immediately. There were 2 patients that lung cancer and COLD (Chronic Obstructive Pulmonary Disease), but pneumonia did not occur. Suture failure was very high frequent. However, this complication decreased over time. Conclusion We reported that pneumonia after esophageal cancer surgery deteriorates the prognosis. Suppression of pneumonia by this operation formula can be expected to improve the prognosis.

Left Vocal Cord Palsy as a Presenting Feature of Congenital Cardiac Disease

Ortner’s syndrome describes hoarseness of voice due to left recurrent nerve palsy in association with cardiovascular disease. It is uncommon in adults, usually secondary pulmonary artery dilation, and recognised rarely in children.

Successful treatment with positive airway pressure ventilation for tension pneumopericardium after pericardiocentesis in a neonate: a case report

BackgroundPneumopericardium in neonates is often associated with respiratory diseases, of which positive pressure ventilation (PPV) is an exacerbating factor. Here, we present a neonate case of pneumopericardium after cardiac surgery which was resolved after applying PPV.Case presentationA 28-day-old neonate with left recurrent nerve palsy after aortic reconstruction for interrupted aortic arch developed pericardial effusion. Pericardiocentesis was performed under general anesthesia, and a drainage tube was left in the pericardium. After extubation, stridor gradually exacerbated, following hemodynamic deterioration. A chest X-ray demonstrated pneumopericardium. Upper airway stenosis due to recurrent nerve palsy developed excessive negative pleural pressure, and air was drawn into pericardium via the insertion site of the drainage tube. After tracheal intubation and applying PPV, the pneumopericardium improved.ConclusionPPV does not always exacerbate pneumopericardium. In a patient with pericardial-atmosphere communication, increased inspiration effort can cause pneumopericardium, and PPV is a therapeutic option to alleviate the pneumopericardium.

MS06.05 Transcervical Lymphadenectomies

Introduction: The aim of his study is to analyze the issue of transcervical lympadenectomies for Non-Small-Cell Lung Cancer performed by the techniques of Video-Assisted Mediastinoscopic Lymphadenectomy (VAMLA) and Transcervical Extended Mediastinal Lymphadenectomy (TEMLA). Methods The Pubmed search was performed and there were 27 articles found on VAMLA and 33 articles on TEMLA. After further analysis there were 13 original article on VAMLA and 18 original articles on TEMLA. In the current paper all proven and possible advantages of transcervical lymphadenectomies represented by VAMLA and TEMLA are described. Results The proven advantages of VAMLA and TEMLA: 1. Superior diagnostic value in discovery of the metastatic mediastinal nodes for staging and restaging of NSCLC. 2. bilateral mediastinal lymphadenectomy, more extensive than the techniques of lymphadenectomy used during standard thoracotomy or Video-Assisted Thoracic Surgery (VATS) approaches. Possible advantages include: 1. Improved selection of patients for pulmonary resection for NSCLC 2. Combination of VAMLA/TEMLA with VATS pulmonary resection, 3. Combination of VAMLA/TEMLA with esophegeal resection, 4. Combination of TEMLA and Stereotactic Radiotherapy (SBRT) for advanced NSCLC 5. The use of TEMLA for preoperative staging of mesothelioma, 6. Combination of TEMLA and pulmonary lobectomy through a sole transcevical approach 7. Resection of various metastatic tumors, including thyroid cancer and metastatic mediastinal nodes. 8. Possible impact of VAMLA/TEMLA on improvement of survival for NSCLC patients, which is the most important issue. In case of VAMLA superior survival of patients operated on with the use pulmonary resection with VAMLA in comparison to the pulmonary resection with addition of standard mediastinoscopy. In case of TEMLA no reports on survival has been published, yet Disadvantages of VAMLA/TEMLA include 1. Possible complications, especially the left recurrent nerve palsy 2. Possible delay or elimination of some patients from pulmonary resection due to postoperative complication in case of negative result of VAMLA/TEMLA 3. Scar in the neck (cosmetic) 4. Demanding surgical technique Conclusions 1. Bilateral transcervical lymphadenectomies representd by VAMLA and TEMLA are more extensive than the techniques of lymphadenectomy used during standard thoracotomy or Video-Assisted Thoracic Surgery (VATS) approaches and superior to the other techniques of staging and restaging of NSCLC in regard to the diagnostic value. 2. There are several other possible advantages of TEMLA/VAMLA for the treatment of NSCLC, esophageal cancer, mediastinal tumors and malignant mesothelioma. 3. Possible impact of VAMLA/TEMLA on survival of NSCLC has not been proven, yet. References Hurtgen M, Friedel G, Toomes H et al: Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results. Eur J Cardiothorac Surg 2002;21:348-51 Zielinski M, Szlubowski A, Kołodziej M, Orzechowski S, Laczynska E, Pankowski J, Jakubiak M, Obrochta A. Comparison of endobronchial ultrasound and/or endoesophageal ultrasound with transcervical extended mediastinal lymphadenectomy for staging and restaging of non-small-cell lung cancer. J Thorac Oncol. 2013 May;8(5):630-6. Zielinski M, Hauer J, Hauer L, Pankowski J, Nabialek T, Szlubowski A. Staging algorithm for diffuse malignant pleural mesothelioma. Interact Cardiovasc Thorac Surg. 2010;10:185-9 Zieliński M, Pankowski J, Hauer L et al: The right upper lobe pulmonary resection performed through the transcervical approach. Eur J Cardiothorac Surg. 2007;32:766-769 Singh AK, Hennon M, Ma SJ, Demmy TL, Picone A, Dexter EU, Nwogu C, Attwood K, Tan W, Hermann GM, Fung-Kee-Fung S, Malhotra HK, Yendamuri S, Gomez-Suescun JA. A pilot study of stereotactic body radiation therapy (SBRT) after surgery for stage III non-small cell lung cancer. BMC Cancer. 2018 Nov 29;18(1):1183. https://doi.org/10.1186/s12885-018-5039-5. Turna A, Demirkaya A, Ozkul S, Oz B, Gurses A, Kaynak K. Video-assisted mediastinoscopic lymphadenectomy is associated with better survival than mediastinoscopy in patients with resected non-small cell lung cancer. J Thorac Cardiovasc Surg. 2013 Oct;146(4):774-80. https://doi.org/10.1016/j.jtcvs.2013.04.036. Epub 2013 Jun 15. Li X, Wang W, Zhou Y, Yang D, Wu J, Zhang B, Wu Z, Tang J. Efficacy comparison of transcervical video-assisted mediastinoscopic lymphadenectomy combined with left transthoracic esophagectomy versus right transthoracic esophagectomy for esophageal cancer treatment. World J Surg Oncol. 2018 Feb 9;16(1):25. https://doi.org/10.1186/s12957-017-1268-3. Call S, Obiols C, Rami-Porta R, Trujilo-Reyes JC, Iglesias M, Saumench R, Gonzalez-Pont G, Serra-Mitjans M, Belda-Sanchís J. Video-Assisted Mediastinoscopic Lymphadenectomy for Staging Non-Small Cell Lung Cancer. Ann Thorac Surg. 2016 Apr;101(4):1326-33. https://doi.org/10.1016/j.athoracsur.2015.10.073. Epub 2016 Jan 21. .Kim HJ, Kim YH, Choi SH, Kim HR, Kim DK, Park SI. Video-assisted mediastinoscopic lymphadenectomy combined with minimally invasive pulmonary resection for left-sided lung cancer: feasibility and clinical impacts on surgical outcomes†. Eur J Cardiothorac Surg. 2016 Jan;49(1):308-13. https://doi.org/10.1093/ejcts/ezv077. Epub 2015 Mar 11 Zielinski M. Transcervical Resection of the Mediastinal Tumors. In Zielinski M, Rami-Porta R (eds). Transcervical Approach in Thoracic Surgery. Springer 2014, pages 141-148.

Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms

ObjectiveFemale sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair. MethodsWe searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes. ResultsFrom 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival. ConclusionsWomen undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period.

Open repair of descending and thoracoabdominal aortic aneurysms in octogenarians

ObjectiveDespite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. We analyzed our results for DTA/TAAA repair in these elderly patients. MethodsOur institutional aortic database was queried to identify those ≥80 years old and those <80 years old undergoing open DTA/TAAA repair. Logistic and Cox regression analyses were used to account for confounders and to identify predictors of perioperative and long-term outcomes. ResultsFrom 1997 to 2017, there were 783 patients who underwent open repair of DTA or TAAA; 96 (12.3%) were ≥80 years old. Octogenarians were more likely to be female (P = .018), with chronic pulmonary disease (P = .012), severe peripheral vascular disease (P < .001), and hypertension (P = .025). Degenerative aneurysms were more common among octogenarians (P < .001), whereas chronic and acute dissections were more common among those younger than 80 years (P < .001 for both). Operative mortality was 5.6% and was not negatively affected by advanced age (<80 years, 5.7%; ≥80 years, 5.6%; P = .852). Other than an increased incidence of left recurrent nerve palsy in the younger cohort (<80 years, 6.7%; ≥ 80 years, 1.0%; P = .029), there were no significant differences in the incidence of major postoperative complications. Logistic regression modeling showed that age ≥80 years was not predictive of operative mortality or postoperative complications. A greater percentage of octogenarians had aortic reconstruction with a clamp and sew strategy (85.4% vs 61.6%; P < .001), which led to significantly shorter cross-clamp times in this cohort (26.6 minutes vs 30.7 minutes; P < .004). In octogenarians, the incidence of major postoperative adverse events was associated with extent II aneurysms (odds ratio, 2.6; P < .025). Short- and long-term survival was significantly reduced in octogenarians. ConclusionsIn select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk. A simplified surgical approach may provide the best opportunity for a successful outcome.

Aortic Arch Replacement with Frozen Elephant Technique - A Single Center Experience Evaluating the Neurological Outcome

Introduction: A modern concept for the treatment of extensive aortic disease involving the aortic arch and the proximal descending aorta is the frozen elephant trunk (FET) technique. The perioperative incidence of spinal cord ischemia and stroke is reported to be up to 24% and 16%, respectively. The results on neurological outcome with the FET technique are presented. Methods: Between July 2011 and August 2014, 33 consecutive patients underwent extensive thoracic aorta surgery using the FET technique (n = 11 E-vita hybrid open stent graft, n = 22 Thoraflex hybrid graft). Root replacement was performed in 38.7% (Bentall n = 9, David procedure n = 3) and additional bypass grafting in 6.1% (n = 2). Mean age of these high-risk patients (mean Euroscore II 13.2 ± 15.7) was 63.2 ± 10.7 years (75.8% males). Indications for surgery were as follows: extensive degenerative aneurysm (33.3%, n = 11), acute (36.4%, n = 12), and chronic (30.3%, n = 10) type A dissection. Of these, 3 patients had acute aortic rupture and 3 patients suffered from Marfan syndrome. About one quarter (24.2%, n = 8) were reoperations. Preoperative neurological pathologies were as follows: paraparesis n = 1, monoparesis n = 2, impaired consciousness n = 2. In addition, 4 patients had already been intubated at the referring clinic. For perioperative neurological protection deep hypothermia (< 25°C) and bilateral antegrade perfusion were used and cerebral oxygenation was monitored by NIRS. Results: Cardiopulmonary bypass, aortic clamping, cerebral perfusion, and circulatory arrest times were 262 ± 79, 143 ± 63, 88 ± 31 and 80 ± 28 minute, respectively. The 30-day mortality was 15.2% (n = 5). Of these, 4 patients underwent emergency surgery. Only 1 patient who underwent elective FET died (3%). Permanent and temporary neurological deficit occurred in 6.3% (n = 2) and 15.2% (n = 5), respectively. Paraplegia occurred in 1 patient (3%) who had previous complete thoracoabdominal endovascular stenting. Left recurrent nerve paralysis was observed in 22.6% (n = 7). Conclusion: The above-mentioned regime which involves bilateral antegrade cerebral perfusion in combination with deep hypothermia provides adequate protection for the spinal cord and the brain even during longer periods of circulatory arrest. Due to anatomical reasons, the left recurrent nerve is difficult to protect.

Left subclavian artery revascularization as part of thoracic stent grafting†

Intentional covering of the left subclavian artery (LSA) as part of thoracic endovascular aortic repair (TEVAR) can cause (posterior) strokes or left arm malperfusion. LSA revascularization can be done as prophylaxis against, or as treatment of, these complications. We report our experience with the surgical technique, indications and the results of LSA revascularization. Between 2000 and 2013, 51 patients of 444 patients who were treated by TEVAR, had LSA revascularization. All elective patients had a preoperative work-up with magnetic resonance angiography to evaluate the circle of Willis. In all, surgical access was through a left supraclavicular incision only. The majority (90%) had prophylactic LSA revascularization because of incomplete circle of Willis and or dominant left vertebral artery (LVA) (n=29), patent left internal mammary artery (n=1), prevention spinal cord ischaemia (SCI) (n=2), prevention left arm ischaemia due to small LVA (n=2) and LVA origin in arch (n=1). Fourteen percent had secondary revascularization, either immediate because of malperfusion of the left arm (n=2) or late after TEVAR because of persisting left arm claudication (n=5). In 12 patients, the following early complications were observed: re-exploration for bleeding, n=1; left recurrent nerve paralysis, n=2; left phrenic nerve paralysis, n=1; left sympathetic chain neuropraxia, resulting in Horner's syndrome, n=3; Chyle duct lesions, resulting in persistent Chyle leakage, n=3. Neither strokes nor SCI was observed. One patient experienced occlusion of the bypass at 6 months. The present study shows that the procedure of LSA revascularization as part of TEVAR is safe with low morbidity consisting of mainly (transient) nerve palsy.

Diffuse large B-cell lymphoma of the thyroid which caused esophageal fistula

We describe a rare case of thyroidal Epstein–Barr virus-positive diffuse large B-cell lymphoma of the elderly (EBV+DLBCLe) in which diagnosis was difficult and spontaneous esophageal fistula developed. A 79-year-old woman presented with acute swelling of the anterior neck with tenderness, general fatigue, and continual fever. Malignant lymphoma of the thyroid was suspected. Histologically, the thyroid lesion showed extensive necrosis, including a few Ziehl–Neelsen-positive substances. No evidence of tuberculosis was detected by any other examinations. While performing examinations, left recurrent nerve palsy and a tumorous lesion in the pharynx appeared. Computed tomography and gastrointestinal fiberscopy revealed esophageal fistula. Biopsy specimens from the pharyngeal lesion showed diffuse proliferation of large atypical lymphoid cells that were strongly positive for CD20 and EBV early RNAs. The final diagnosis was thyroidal EBV+DLBCLe with infiltration of surrounding organs. The esophageal fistula had healed 6 months after beginning treatment of EBV+DLBCLe.

Ortner's syndrome associated with hypertensive cardiac disease

We report an 83-year-old man complaining of hoarseness and dyspnea on exertion for two days. He had stopped taking an antihypertensive drug for three months. Physical examinations on admission revealed the left vocal cord fixed in the paramedian position. Radiological examinations showed severe pulmonary congestion, cardiomegaly, pleural effusion, and swelling of the mediastinal lymph nodes. Plasma level of BNP was elevated. These findings indicated pulmonary congestion due to left heart failure. Treatment with diuretic was started from the date of admission. Along with relief of symptoms from heart failure, his hoarseness improved and almost disappeared three weeks after the beginning of treatment. Laryngoscope demonstrated improvement in the left recurrent nerve paralysis on the 28th day after the beginning of treatment.

Primary Leiomyosarcoma of the Anterior Mediastinum Encasing the Aortic Arch, Left Common Carotid and Left Subclavian Arteries

A 66-year-old man presented with a one month history of hoarseness. Left recurrent nerve palsy and a left upper mediastinal mass were observed by an otorhinolaryngologist who referred the patient to our department. Chest computed tomography showed a superior mediastinal mass, which seemed to involve the left common carotid and left subclavian arteries from the greater curvature of the aortic arch. The innominate vein was compressed, and collateral circulation was well developed. The left upper lobe of the lung was also seemed involved. A mediastinal biopsy conducted via left thoracoscopy revealed a malignant spindle cell tumor. The mediastinum was irradiated (40 Gy), and surgical extirpation was subsequently undertaken 3 weeks later. The tumor was successfully removed without the use of extracorporeal circulation. Because only smooth muscle actin was focally but strongly expressed immunohistochemically, leiomyosarcoma was confirmed. The patient was discharged on day 14. A solitary left pleural metastasis was observed and resected 12 months after the surgery and the patient is well without further recurrence 16 months after the initial surgery.

Anatomical bases of left recurrent nerve lesions during mediastinoscopy

The mechanism of left recurrent laryngeal nerve palsy after cervical mediastinoscopy remains unclear. Our aim is to describe the anatomical bases of this complication. Video-assisted mediastinoscopy was performed on ten fresh human cadavers with simultaneous dissection of the left recurrent nerve. Three dissection areas could be described regarding the risk of left recurrent nerve damage: a low risk area, along the right wall and before the upper part of the anterior wall of the trachea; an area at high risk of indirect stretch-induced lesions, between the lower part of the anterior wall of the trachea and the aorta; -an area at high risk of direct injury, against the lower part of the left wall of the trachea. Dissection between the trachea and the aorta causes traction on the left recurrent nerve. Indirect stretch-induced injury is probably a frequent mechanism of left recurrent nerve palsy during mediastinoscopy.

Hybridoperation zur Behandlung eines distalen Aortenbogenaneurysmas mit linksseitiger Recurrensparese – Ortner-Syndrom

A left recurrent nerve palsy caused by left atrium hypertrophy, dilatation of the left pulmonary artery or a thoracic aortic arch aneurysma is named Ortner's syndrome. We report the case of a 84-year old male patient with a posttraumatic aneurysm of the distal aortic arch known for 20 years, which became symptomatic by new presentation of an acute hoarseness caused by a left sided recurrent nerve palsy due to rapid aneurysma expansion. Because of the aneurysma localization, the advanced age and the patient?s morbidity he was treated by a hybrid procedure with an extrathoracic reconstruction of the supraaortic arteries by a right to left carotid-carotid bypass and transposition of the left subclavian artery followed by endovascular implantation of aortic stent grafts for aneurysma exclusion. The left recurrent nerve palsy remained unchanged until now. Aneursms of the distal aortic have to be considered as a rare cause of a left-sided recurrent nerve palsy. Recent advances in endovascular therapy combined with supraaotic vascular reconstruction offers a less invasive therapeutic option for some of these patients.

Chylous leak after cervical mediastinoscopy

Chylous leak after cervical mediastinoscopy

Recurrent Nerve Paralysis after Esophagectomy for Carcinoma of the Thoracic Esophagus.

Between 1985 and 2000, 128 esophageal cancer patients underwent esophagectomy with resulting vocal cord paralysis (VCP). They were disease free at least 1 year after surgery. They were divided into Group A (63 patients operated on between 1985 and 1993) and Group B (65 patients operated on between 1994 and 2000). In 1993, we revised our surgical techniques in removing the recurrent nerve lymphatic chains in order to reduce postoperative VCP. Thus, we could compare these two groups of patients. Only two patients (3.1%) of Group B complained of severe hoarseness 1 year after surgery, as compared to 18 patients (28.6%) in Group A. Of the 108 patients who did not complain of severe hoarseness, the mean duration of their difficulty in talking was 3.3 months for Group B and 6.0 months for Group A. The incidence of the persistent VCP 1 year after surgery significantly decreased from 57.1% in Group A to 24.6% in Group B, mainly owing to a recovery from left recurrent nerve palsy. In the group of patients with severe hoarseness 1 year after surgery, daily activity and percentage of ideal body weight at 1 year had deteriorated. Severe hoarseness, therefore, does not seem to be an inevitable consequence of esophagectomy for cancer but rather to surgical maneuver and a poor nutritional state. From the viewpoint of quality of life, the permanent nerve paralysis caused by esophageal cancer surgery is worrisome and a factor in the deterioration of daily activity until it is adequately treated.

Retroesophageal Subclavian Artery Aneurysm Arising from Kommerell's Diverticulum

This report describes a novel technique used for management of retroesophageal subclavian artery aneurysm arising from Kommerell's diverticulum. The procedure consists of endoaortic exclusion of the aneurysmal neck, using a prosthetic patch after sternotomy during circulatory arrest, and antegrade cold blood cerebroplegia. The advantages of this technique are avoidance of hemorrhagic complications during clamping of the aneurysmal neck, limiting of the extent of dissection of the aortic arch, and elimination of the risk of inadvertent left recurrent nerve paralysis. Antegrade cold blood cerebroplegia provides good cerebral protection and decreases the duration and consequences of extracorporeal circulation.

TWO CASES OF MEDIASTINAL SCHWANNOMA ORIGINATING FROM THE INTRATHORACIC VAGAL NERVE

This paper presents two cases of mediastinal schwannoma originating from the intrathoracic vagal nerve together with a review of 65 cases given detailed explanations in the Japanese literature. The first case: A 48-year-old man was admitted to the hospital because of an abnormal shadow in a chest X-ray film. Under a diagnosis of left mediastinal tumor, an operation was carried out. The tumor and string attached to the tumor were resected en bloc through a thoracotomy. Pathological diagnosis was schwannoma. Left recurrent nerve paralysis was evident by postoperative horseness. We thought that the tumor was a schwannoma arising from the vagal nerve proximal to the origin of the recurrent nerve. The second case: A 51-year-old woman was admitted to the hospital because of an abnormal shadow in a chest X-ray film. From a CT scan and a MRI we diagnosed preoperatively that the tumor arose from the vagal nerve distal to the origin of the recurrent nerve. Thoracoscopic surgery was performed. The tumor was resected with transection of the vagal nerve. Pathological diagnosis was schwannoma. The postoperative course was uneventful. Mediastinal schwannoma originating from the intrathoracic vagal nerve presents difficulty in preoperative diagnosis. Although it uncommonly appears, some malignant cases have been reported and hence complete resection is desirable. However, we have to consider treatments which differ from case to case in terms of postoperative complications.

Left recurrent nerve paralysis associated with complete lung collapse with consolidation in an adult with cystic fibrosis

At a routine outpatient visit, a 35year-old Caucasian man with pancreatic-sufficient CF complained of a 2-month history of a painless hoarse voice. The diagnosis of CF had been made only 3 yr previously at the age of 32 years, when he presented with a 5-yr history of recurrent chest infections and was found to have bronchiectasis. The diagnosis of CF was confirmed by abnormal sweat and nasal potential difference tests, and genetic analysis confirmed heterozygosity for the 6 F508 deletion (no other defect identified). At this stage, sputum culture yielded Pseudomonas aeruginosa and his lung function was impaired markedly: FEV, 1.2 1 (34% predicted), FVC 1.5 1 (36% predicted), arterial pO2= 6.2 kPa on air. Electrocardiogram (ECG) findings were consistent with pulmonary hypertension. Longterm oxygen therapy and postural drainage were instituted. Six months later, he was admitted to his local hospital with an acute pulmonary exacerbation. At this admission, he demonstrated signs of left lung collapse with consolidation, which were