Technical advances in extracorporeal membrane oxygenation (ECMO) have increased the number of cases that maintain longer duration. Long-term use of ECMO results in ECMO-related complications. Anticipation of the life-threatening mechanical complications and their management are critical for safe ECMO. In this study, we analyzed the incidence, nature, and risk factors of life-threatening mechanical complications during ECMO support. Furthermore, we presented our bedside algorithms to manage catastrophic ECMO complications. Data from 549 patients who underwent ECMO between December 2008 and December 2018 were retrospectively analyzed. The incidence of all life-threatening mechanical complications was 4.0%. Accidental decannulation (1.3%) was most common, followed by abrupt falling circuit flows (1.1%), pump failure (1.1%), circuit rupture (0.4%), and air in circuit (0.2%). Most (90.9%) of life-threatening events required circuit and cannula change, while 9.1% required vein collapse relief procedure. There was no death related to the event; however, six (27.3%) died during ECMO due to the underlying disease for which ECMO was required, and three (13.6%) died after weaning from ECMO. Multivariate regression analysis showed that awake ECMO and long-term ECMO support were significantly associated with life-threatening mechanical complications (p < 0.01). Our algorithm safely managed catastrophic ECMO problems without event-related deaths.

Park JM, et al. Yonsei Med J. 2023 Dec;64(12):730-737. https://doi.org/10.3349/ymj.2023.0104

Joohyung Son, M.D., Changwon Shin, M.D.. J Chest Surg 2022;55:255-64. https://doi.org/10.5090/jcs.22.057

P21-activated kinases (PAKs) are serine/threonine protein kinases that contribute to several cellular processes. Here, we aimed to determine the prognostic value of PAK1 and its correlation with the clinicopathological characteristics and five-year survival rates in patients with non-small cell lung cancer (NSCLC). We evaluated PAK1 mRNA and protein expression in NSCLC cells and resected tumor specimens, as well as in healthy human bronchial epithelial cells and adjacent healthy lung tissues, respectively, for effective comparison. Immunohistochemical tissue microarray analysis of 201 NSCLC specimens showed the correlation of PAK1 expression with clinicopathological characteristics. The mRNA and protein expression of PAK1 were 2.9- and 4.3-fold higher in six of seven NSCLC cell types and human tumors (both, p < 0.001) than in healthy human bronchial epithelial BEAS-2B cells and adjacent healthy lung tissues, respectively. Decreased survival was significantly associated with PAK1 overexpression in the entire cohort (χ² = 8.48, p = 0.0036), men (χ² = 17.1, p < 0.0001), and current and former smokers (χ² = 19.2, p < 0.0001). Notably, epidermal growth factor receptor (EGFR) mutation-positive lung cancer patients with high PAK1 expression showed higher mortality rates than those with low PAK1 expression (91.3% vs. 62.5%, p = 0.02). Therefore, PAK1 overexpression could serve as a molecular target for the treatment of EGFR mutation-positive lung cancer, especially among male patients and current/former smokers.

Hyo Yeong Ahn, M.D., Yeong Dae Kim, M.D., Hoseok I, M.D., Jeong Su Cho, M.D., Jonggeun Lee, M.D., Joohyung Son, M.D.. Korean J Thorac Cardiovasc Surg 2016;49:456-60. https://doi.org/10.5090/kjtcs.2016.49.6.456

Minimally invasive surgery (MIS) has become a mainstay for lung cancer treatment because of comparable outcomes to open thoracotomy; however, chylothorax remains a notable complication, which can lead to protein and electrolyte depletion, malnutrition, and increased morbidity. This study aimed to (1) determine the incidence of chylothorax after MIS for lung cancer; (2) identify pertinent risk factors; (3) evaluate the effectiveness and limitations of a predominantly conservative treatment algorithm; and (4) assess perioperative changes in nutritional status associated with chyle leakage. This single-center, retrospective cohort study included patients who underwent multiport or single-port video-assisted thoracoscopic surgery, or robot-assisted thoracoscopic surgery at our institution between September 2009 and August 2024. Chylothorax was diagnosed based on visual and laboratory confirmation (pleural fluid triglyceride ≥ 110 mg/dL or high lymphocyte fraction), and was managed using a stepwise protocol including total parenteral nutrition (TPN), no-fat or low-fat diet, and pleurodesis as needed. If high output persisted or recurred, reoperation or thoracic duct ligation was considered. Patients were categorized into high-volume (HV) or low-volume chylothorax groups, using a threshold of 500 mL/day to reflect severity. The outcomes included chest tube duration, hospital stay, perioperative nutritional parameters (albumin, white blood cell count, and total lymphocyte count), and nutritional risk scores. Among the 1,038 patients included, 21 (2.0%) developed chylothorax. Risk factors for chylous leakage included right-sided tumors (p = 0.04), single-port or robotic approaches (p = 0.017), and a higher median number of dissected lymph nodes (p = 0.005) and N2 nodes (p = 0.001). Patients with chylothorax had a significantly longer chest tube duration (p < 0.001) and postoperative hospital stay (p < 0.001). Although conservative management was successful in most cases, the HV group had greater drainage volumes, more frequent pleurodesis, extended dietary interventions, and delayed recovery. Notable declines in albumin and total lymphocyte counts, and increased nutritional risk scores, underscored the metabolic burden posed by chylothorax. Chylothorax remains an important complication of MIS for lung cancer. Conservative measures are effective for many patients; however high-output chylothorax can prolong hospital stay and compromise nutritional status. Early recognition of the risk factors and judicious consideration of interventional and surgical options are essential.