胸部外科
Volume 58, Issue 9, 2005
Volumes & issues:
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胸部外科の指針
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Bulky N2,T4非小細胞肺癌例に対するinduction chemotherapyの有用性
58巻9号(2005);View Description Hide DescriptionIt is controversial that the effect of induction chemotherapy for bulky N2, T4 non-small cell lung cancer. We examined a retrospective study to assess this issue. Ten patients with bulky N2, T4 disease were given bronchial arterial infusion consisting of cisplatin(60mg/m)and docetaxel hydrate(60mg/m)intravenously, followed by standardized surgical resection(group A). Thirty patients had pathological N2, T4 disease after surgery(group B). Pathologically downstaging was seen in 6patients in group A. The overall long-term survival at 1-, 2-year were 87.5,87.5% in group A. The long-term survival at 1-,2-,and 5-year were78.9,49.8, 43.6% in group B. There was no statistically significant difference in survival between both groups(p=0.3015). The effect of induction chemotherapy for bulky N2,T4non-small cell lung cancer was not demonstrated in our data. We suggest that our induction chemotherapy in group A was effective on T4disease. A prospective study is needed to investigate our regimen.
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今月の臨床
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肺動脈弁欠損および右室異形成を伴った三尖弁閉鎖に対するFontan型手術
58巻9号(2005);View Description Hide DescriptionWe report a case of successful staged repair of tricuspid atresia with dysplasia of the right ventricular myocardium and absence of the pulmonary valve. The patient underwent the modified Blalock-Taussig shunt operation at 1 month the bidirectional Glenn procedure at 11 months, and the total cavopulmonary connection procedure using extracardiac graft at 2years. It is important to prevent the left ventricular outflow tract obstruction(LVOTO)caused by the non-functioning right ventricle when the Fontan completion. We were safely able to disconnect the pulmonary trunk from the right ventricle using the transesophageal echocardiography to evaluate the LVOTO during operation. -
胸壁原発軟骨肉腫
58巻9号(2005);View Description Hide DescriptionWe report 2patients with chondrosarcoma of the chest wall. They were a 67-year-old woman(case 1)with an anterior chest wall tumor and a 68-year-old woman(case 2)with a painful rib tumor. Their computed tomography(CT)both revealed calcified tumors. Case1underwent a wide resection by partial sternectomy, with free surgical margins. Case 2 underwent tumor resection with the posterior part of the 3rd rib,with positive surgical margin in the vertebral site, and received adjuvant radiotherapy. Both patients were pathologically diagnosed as having gradeⅡ chondrosarcoma. In their postoperative courses, they are free from recurrence. Wide resection is likely to be the key to successful management of chest wall chondrosarcoma.
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今月の話題
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心臓腫瘍と思われたAspergillus心膜膿瘍
58巻9号(2005);View Description Hide DescriptionWe report a rare case of 34-year-old man who was diagnosed as cardiac tumor after therapy for acute lymphatic leukemia. Echocardiography and computed tomography(CT)showed that the tumor was located from the right atrium to the right ventricle and about 6.0cm in diameter. Resection of the tumor was performed under cardiopulmonary bypass. The histological findings revealed pericardial abscess by Aspergillus. -
血痰と.胞内出血をきたした多発性肺.胞症に併発した肺大細胞癌―本邦報告20例の分析とともに
58巻9号(2005);View Description Hide DescriptionA 50-year-old man with continuous hemosputa and large hematoma of left upper lobe contiguous to bilateral emphysematous bullous disease was admitted for surgery to stop hemorrhage and to resect left lung hematoma and multiple bullae. Bullectomy and neodymium yttrium aluminum garnet(Nd-YAG)laser irradiation to bullae of left upper lobe performed successfully with maximum preserved pulmonary function of it. Pathological examination, however, revealed anaplastic carcinoma inside bulla of S1+2c with minimal invasion into adhered parietal pleura(p 3). Left upper lobectomy was carried out with complete mediastinal lymph node dissection(ND 2b). The final pathological diagnosis was large cell carcinoma of left S1+2c with the staging pT3N0M0 and stageⅡ. The patient lives actively in daily life more than 7 years without any recurrence. Clinical analysis of Japanese 20cases of lung carcinoma with initial signs of hemosputa and/ or hemoptysis contiguous to emphysematous bullae elucidate following important facts. Hemosputa and hemoptysis play important role for early finding and diagnosis of lung cancer contiguous to bullous disease, especially in patients of early clinical stage with or without computed tomography(CT)exams and promise to better surgical prognosis and survivals as compared with non hemosputa ones.
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臨床と研究
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CABGが固有冠状動脈狭窄病変へ及ぼす影響
58巻9号(2005);View Description Hide DescriptionThis study was designed to evaluate proximal native coronary stenosis(PNCS)after coronary artery bypass grafting(CABG). In 36 patients undergoing postoperative coronary arteriography, the PNCS bypassed with internal thoracic artery(ITA), saphenous vein graft(SVG)and right gastroepiploic artery(RGEA)progressed in 9 of 23 vessels(39%), in 15 of 28 vessels(53%),in 4of11vessels(36%),respectively. Stenosis of no grafted coronary vessels progressed in 3of 26vessels(11%). Twelve native coronary vessels(9:99% and 3:90% stenosis vessels)bypassed with grafts were obstructed. This study confirms that the PNCS progresses significantly by CABG just after the operation and that it tends to progress highly with SVG in comparison with arterial grafts such as ITA or RGEA. Because operative mortality for repeated CABG is approximately twice as high as that for primary CABG, it is important to decide whether early postoperative percutaneous transluminal angioplasty is needed or not, in considering of future graft failure and stenosis progression of the native coronary vessels by CABG.
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手術術式
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癌性気道狭窄に対するマイクロターゼとpotassium titanyl phosphate(KTP)レーザーの併用治療経験
58巻9号(2005);View Description Hide DescriptionAbout2 years after right lower lobectomy for anadenocarcinoma in the right lung,an 80-year-old man had a reccurent tumor in tracheocarinal lymph nodes. Although concurrent chemoradiotherapy was performed,there was no change(NC)and the tumor grew back slowly. He was admitted to our hospital with exertional dyspnea and stridor2years later. The bronchoscopic microwave coagulation therapy was performed in the right main bronchus. After potassium titanyl phosphate(KTP)laser therapy had been performed in the tracheocarinal lumen,an expandable metallic stent was performed. The postopertive course was uneventful.
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手術時の工夫
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肺動脈絞扼テープの工夫
58巻9号(2005);View Description Hide DescriptionPulmonary artery banding remains a useful procedure for special conditions. A 3-month-old girl diagnosed as Down syndrome with atrioventricular septal defect underwent pulmonary artery banding. We used polyester tape smeared with Bone Wax for this pulmonary artery banding. After 7 months period, the tape was easily dissected from surrounding tissue and removed at radical operation. Microscopic appearance showed that the tape was intact and no evidence of inflammation or mineralization. We believe Bone Wax smeared polyester tape accomplishes well as silicone impregnated one.
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臨床経験
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単独CABG後心房細動
58巻9号(2005);View Description Hide DescriptionPostoperative atrial fibrillation(Af)remains a significant source of morbidity after coronary artery bypass grafting(CABG). Prophylactic therapy with β-adrenergic blockers or amiodarone hydrochloride is reported to reduce the incidence of Af. We studied the incidence of Af retrospectively and considered the risk factors for it. Ninety-three patients who underwent isolated CABG from April 2003to March 2004are included in this study. Postoperative Af was observed in 22(25%)patients. Ten of them were operated on off-pump procedure, and 14had any type of β-adrenergic blockers preoperatively. The mean age of the group of postoperative Af is 69.7±9.2years old(older than the non-Af group:65.5±10years old,p=0.087). And the preoperative left atrial size was larger in the Af group than in the non-Af group(43.4±6.1versus 40.6±5.4mm, p=0.064)Major embolic complication occurred in only 1(1.1%)patient of non-Af group. We observed postoperative Af in 25% of patients after CABG. Older age and larger left atrial size may relate to the incidence of Af,and appropriate anticoagulant therapy and medication of β-blockers are important for the patients who have such risk factors. -
びまん性肺疾患に対する胸腔鏡下肺生検にて偶然発見された肺腺癌
58巻9号(2005);View Description Hide DescriptionWe here presented 2 cases of interstitial pneumonia with lung adenocarcinoma incidentally diagnosed by partially resected lung for diffuse pulmonary disease. Case 1:A 78-year-old female was admitted to the hospital complaining of productive cough and general fatigue. The chest computed tomography(CT)revealed diffuse honey comb pattern in bilateral lung field especially in the right lower lung. Video-assisted thoracoscopic lung biopsy was performed and was diagnosed as diffuse spreading well differentiated adenocarcinoma. Case 2:A 59-year-old male was admitted to the hospital complaining of dyspnea and general fatigue. The chest X-ray revealed right pneumothorax and chest CT revealed diffuse honey comb pattern and bullae in bilateral lung field and fibrous tumor-like lesion in the right middle lung. Video-assisted thoracoscopic lung biopsy was performed and was diagnosed as pulmonary fibrosis with papillary adenocarcinoma. Conclusion:It is important to examine carefully the specimen obtained from thoracoscopic lung biopsy even if interstitial pneumonia is strongly suspected.
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症例
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胸部感染性大動脈瘤破裂に対しrifampicin浸漬人工血管置換と大網充填を施行した1例
58巻9号(2005);View Description Hide DescriptionA 73-year-old man was admitted for investigation of back pain, blood-stained sputum, and a high fever. Computed tomography(CT)showed a pseudoaneurysm in the descending aorta and intravenous antibiotic therapy was begun immediately after blood had been taken for culture. However, his temperature continued to spike daily, up to 38℃, and his CRP was also elevated. The blood cultures were negative. The aneurysm ruptured and we replaced the descending aorta with a rifampicin(RFP)-soaked vascular prosthesis, and wrapped it with greater omentum. Postoperative antibiotic therapy with vancomycin hydrochloride,RFP,and amikacin sulfate was continued for 8weeks. The patient recovered uneventfully. Thus, an infected aneurysm was effectively treated with a RFP-soaked vascular prosthesis and omentopexy. -
人工肛門造設術後のNorwood型手術
58巻9号(2005);View Description Hide DescriptionWe encountered a baby who was diagnosed with anal atresia,interruption of aortic arch(type B),aortic stenosis,mitral stenosis,single atrium,large ventricular septal defects,aberrant origin right subclavian artery. We operated on him using the Norwood procedure after a colostomy. Aortic arch was reconstructed by interposing with an 8mm graft and the right ventricular-pulmonary artery(RV-PA)conduit was chosen for pulmonary flow. We closed the sternum 6days after the Norwood procedure. We extubated him 16days after delayed sternal closure. There was no trouble with his stoma and no sign of infection. The postoperative echocardiography didn’t show the finding which left pulmonary artery was stenotic, but the lung perfusion schintigraphy revealed an imbalance in the distribution of lung perfusion. He was discharged 70days after undergoing the Norwood procedure. -
大動脈炎症候群に対するCABGの1例
58巻9号(2005);View Description Hide DescriptionWe present a case of surgical treatment for a coronary lesion due to aortitis syndrome. A 41-year-old woman, suffering from aortitis syndrome and under prednisolone(PSL)therapy, underwent coronary artery bypass grafting(CABG). Surgical treatment was performed according to the aortic no-touch technique, but the patient showed a poor cardiac performance 5days after the operation. This accident was resolved by increasing the PSL dose. Aortitis syndrome treated with PSL needs careful perioperative management besides an operative procedure. -
下肢急性動脈閉塞で発症した真菌性心内膜炎の1例
58巻9号(2005);View Description Hide DescriptionFungal endocarditis caused by Candida species is associated with high morbidity and mortality. A combination of surgical resection and antifungal drug therapy is the golden standard for treatment. We reported a case of fungal endocarditis due to Candida lusitaniae found at onset of lower limb acute aortic occlusion cured by emergency operation. This case suggests that Candida endocariditis can be managed medically with antifungal drug therapy in life time. -
胸膜腫瘍と類似した胸腔内髄外造血組織に対する手術
58巻9号(2005);View Description Hide DescriptionIntrathoracic extramedullary hematopoiesis is a rare condition accompanying chronic hematologic disease. We present a case of chronic gastric ulcer in which a posterior mediastinal mass was diagnosed as extramedullary hematopoiesis. We underwent video-assisted thoracoscopic resection safely and successfully. This procedure is relevant and safety procedure for differential diagnosis of patients who have chronic anemia with asymptomatic intrathoracic tumors -
子宮体部癌手術待期中に発見された左房内有茎性球状血栓症の1例
58巻9号(2005);View Description Hide DescriptionAn 80-year-old woman was scheduled to have an operation for uterus cancer. Echocardiography revealed a giant mobile mass in the left atrium with a stalk at posterior wall of the left atrium. There was no significant mitral disease. Due to the risks of sudden circulatory collapse and systemic emboli, an emergency operation was indicated. Right side of the left atrium was opened under cardiopulmonary bypass following median sternotomy. The mass was attached to the posterior wall,1.5cm medial to the right upper pulmonary vein,with a thin stalk as diagnosed preoperatively. The mass(4.2×3.4×3.4cm)was removed very easily. Pathological analysis revealed that the mass was a thrombus mixed with fibrin. A possible cause would be paroxysmal atrial fibrillation and/or hypercoagulative status due to malignancy. Anti-coagulation therapy was initiated postoperatively to prevent recurrence of thrombus. The patient recovered and discharged uneventfully. -
縦隔内進展を呈した頸部巨大血管腫の1例
58巻9号(2005);View Description Hide DescriptionAn asymptomatic69-year-old man was admitted to our hospital for an abnormal shadow on the chest X-ray of a medical examination. He had undergone an operation for a hemangioma in the neck(incomplete resection)39years before admission. Computed tomography(CT)of the neck and chest revealed an giant cystic mass in the neck extended into the mediastinum,severe deviation of the trachea to the right and fluid collection in the mediastinum. It was considered to be a giant hemangioma with mediastinal hemorrhage by the rupture of the tumor. After the large afferent and efferent vessels were identified by angiography and venography,we performed the resection of the tumor. Pathological examination confirmed the diagnosis of arteriovenous hemangioma. -
非典型的なCT所見を呈した後縦隔発生のCastleman病の1例
58巻9号(2005);View Description Hide DescriptionA 41-year-old man was referred to our hospital because of an abnormal mass on a chest X-ray. An enhanced computed tomography(CT)showed a well-defined round mass(30×45×66mm in diameter)that was heterogeneously enhanced owing to central necrotic or cystic change. A 3-dimensional CT demonstrated a couple of feeding arteries to the mass. The mass was completely resected through thoracotomy. Dissection of tight adhesion between the hypervascular mass and the surrounding tissues caused relative amount of hemorrhage during the surgery. The cystic lesion of the mass was fulfilled with brown liquid. The pathological examination revealed the mass as Castleman disease, and scattered cells in the cystic lesion.
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まい・てくにっく
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1枚のシェーマ
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胸部外科医の散歩道
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