胸部外科
Volume 59, Issue 9, 2006
Volumes & issues:
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胸部外科の指針
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マグネシウムによる心臓手術後心房細動予防効果
59巻9号(2006);View Description Hide DescriptionBackground:Atrial fibrillation(AF)is a common complication of cardiac operation. Forthe development of postoperative AF,various risk factors have been identified over the years. Ina recent study,it was detected that low serum magnesium levels was an independent predictor ofAF after coronary artery bypass grafting(CABG). The purpose of this study was to assess theprophylactic effect of intravenous magnesium infusion on postoperative AF.Methods:A total of 62consecutive patients who had elective, first time cardiac operation oncardiopulmonary bypass were prospectively categorized to 2group. In the treatment group, 30patients received 8.3mmol of magnesium sulfate in 100ml of saline solution that was administeredover 4hours, preoperatively, just after admission in the ICU, and at the postoperative day 1,2, 3, and 4.Results:Postoperative AF occurred in 3/30(10.0%)patients in the treatment group and in14/32(43.8%)patients in the control group(p<0.01). The arrhythmia developed on the 2.9postoperative day on average. The postoperative length of hospital stay was significantlyshortened in the treatment group(15.9±4.0days)than that in the control group(20.5±7.0,p<0.01).Conclusion:Our findings indicate that magnesium sulfate infusion is effective for the prophylaxisof post operative AF.
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今月の臨床
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弓部大動脈置換と肺摘除により完全切除しえた浸潤型胸腺腫
59巻9号(2006);View Description Hide DescriptionA 68-year-old male was found an abnormal shadow on chest X-ray and was diagnosed asthymoma by computed tomography(CT)-guided needle biopsy. As the tumor invaded the aorticarch, left main pulmonary artery and the lung, thymectomy combined resection of the surroundingtissues was performed for the complete resection. The aortic arch was replaced with cardiovasculargraft under cardiopulmonary bypass, with the aid of selective cerebral perfusion.The left pneumonectomy was performed because the tumor invaded to the left main pulmonaryartery and to the lung parenchyma. Masaoka stageand histologic type B2 were diagnosedaccording to the World Health Organization classification. The patient has been well withoutrecurrence or metastasis after the surgery for 2 years. A complete resection of the thymomainvaded to great vessels should be performed to expect for the good curability and prognosis
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今月の話題
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右肺無形成および左気管支狭窄を伴った心室中隔欠損
59巻9号(2006);View Description Hide DescriptionWe report a case of ventricular septal defect(VSD)with right pulmonary agenesis and leftbronchial stenosis. Delivery of a male infant was uneventful. Birth weight was 3,050g. At 12days of age, he presented himself with tachypnea and wheezing. Dextrocardia was noted on achest X-ray. Computed tomography (CT) of the chest showed right pulmonary agenesis andsevere narrowing of the left main bronchus. An echocardiogram showed VSD, patent ductusarteriosus (PDA)and pulmonary hypertension (PH). At 22days of age, he was put on ventilator.At 1month of age,pulmonary artery banding and division of PDA were performed throughmedian sternotomy. At 5months of age, weighing 5.0kg, the VSD was closed with a Dacronpatch through median sternotomy. At 6 months of age, tracheostomy was necessitated. At1-year-old, he became free from ventilator.
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手術時の工夫
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術中malperfusionに対し上行大動脈真腔内送血にて対処しえた大動脈解離
59巻9号(2006);View Description Hide DescriptionA 47-year old woman,who was diagnosed as Stanford type A acute aortic dissection,underwentan emergent operation. Because of obesity and bleeding, it was impossible to find the rightaxillary artery. Only we could have for inflow line was the femoral line. After startingcardiopulmonary bypass(CPB)and crossclamping the ascending aorta,mean blood pressure ofthe right radial artery dropped to 15mmHg, suggesting the occurrence of malperfusion. Theascending aorta was immediately transected, and the CPB was ceased. Inflow cannula wasdirectly inserted into the true rumen of the ascending aorta, and resumed the CPB. The meanblood pressure rose up to 80mmHg. Such procedure took about 10 minutes. Abnormal neurologicalfindings were not apparent except for the transient postoperative delirium. The patientwas discharged on the 48th day after operation. It is suggested that this method was useful andsafe to have the new inflow line when emergently necessary -
新しいCABG中枢側自動吻合器における静脈グラフト屈曲予防の工夫
59巻9号(2006);View Description Hide DescriptionIn using the proximal anastomotic system, the anastomotic site should be carefully selected toprevent the kinking of the graft,because the angle of the graft and the aortic wall is perpendicular.There recommended anastomotic sites are the left lateral aortic wall adjacent to thepulmonary artery for the left coronary system grafting and the lower aortic wall adjacent to theright atrium for the right coronary system grafting respectively. When the selection of thesesites are difficult because of the atherosclerotic lesion of the aorta,the short vein graft(2-3cm)was first anastomosed with PAS-Port device to the site free from atherosclerosis. Then,the longvein graft was anastomosed to the short graft with monofilament suture under end-to-sidefashion. The angle of the anastomosis was decided according to the relationship of the aorta andthe target coronary artery to establish a smooth graft line. By this stepwise technique, theoptimal graft design could be obtained without a risk of the kinking of the graft.
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術前・術後管理
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肺悪性腫瘍手術後肺血栓塞栓症
59巻9号(2006);View Description Hide DescriptionFrom January 1994to December 2004,6of 1,034patients(0.58%)with pulmonary malignanttumor developed pulmonary thromboembolism(PTE)after surgery in our department. Five of6patients had primary lung cancer, and 1 had metastatic lung tumor. The surgeries for the 6patients contain 1 exploration thoracotomy, 1 wedge resection, 3 lobectomies, and 1pneumonectomy. The length of time between operation and making diagnosis of PTE was 2-7days. All 6patients initially showed symptoms of desaturation and tachycardia. Chest computedtomography(CT)was the most useful diagnostic method. In all cases, we started intravenousadministration of unfractionated heparin sodium immediately after making diagnosis. In2 cases, we needed to add thrombolysis by urokinase because of their serious condition. Onepatient in whom the establishment of diagnosis took longer time died on the postoperative day9,in spite of the removal of the thrombus by percutaneous approach. The other 5patients madea recovery and observed no signs of recurrence of PTE after 6-month anticoagulant therapy bywarfarin potassium. PTE can be treated only with anticoagulant therapy if we confirm thediagnosis and start the treatment immediately after the first episode.
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臨床経験
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脊椎カリエスを伴う縦隔リンパ節結核腫
59巻9号(2006);View Description Hide DescriptionA 65-year-old male presented with a chief complaint of back pain. Chest computed tomography(CT)demonstrated partially calcified enlargements of the anterior mediastinal lymph nodesand pleural effusion in both lungs. His spondylous lesion rapidly progressed and developed intoquadriparesis approximately 2months after he noticed the back pain. We could not determinewhether the lesion was an invasion of the spinal cord by a carcinoma of unknown primary ormalignant lymphomas. Therefore,we performed a lymph node biopsy using a thoracoscope for a definitive diagnosis. Histopathology showed tuberculoma with epithelioid cell growth andimages of previous scars. However, the staining method for tubercle bacillus did not reveal thepresence of tubercle bacillus. As in this case, not all cases of tuberculoma present tuberclebacillus. Therefore, even with poor, suspicious findings for tuberculosis, we should alwaysconsider tuberculosis. Old tuberculoma may relapse and rapidly progress. Therefore, we concludedthat a biopsy should be performed when tuberculoma is suspected. -
肺内気管支原性嚢胞
59巻9号(2006);View Description Hide DescriptionBronchogenic cysts are commonly found in the mediastinum, but occasionally in lung parenchyma.We report 3 patients with intrapulmonary bronchogenic cysts. A female presentedback pain and a large cystic lesion with an air-fluid level on chest X-ray and computed tomography(CT). Another female was asymptomatic. A well-defined round mass with soft tissueintensity on magnetic resonance imaging(MRI)was found. A girl with repeated pulmonaryinfection and treatment in hospital for several years presented pulmonary infiltrate, air-fluidlevel, and oval linear shadow on X-rays. All patients underwent lobectomy because of the sizeand the non-anatomical location of their lesions. Definite diagnosis on their lesions was determinedby pathological study.Several small communications between the cyst and adjunctive parenchyma was found in thesymptomatic girl,while the cyst was isolated from surrounding parenchyma in the asymptomaticfemale. We suggest symptoms and various presentations on imaging modalities in patients withintrapulmonary bronchogenic cysts might relate to the amount of original communicationbetween their cysts and native lung.
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症例
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ステントレス生体弁を用いて大動脈基部・上行大動脈置換術およびCABGを行った1例
59巻9号(2006);View Description Hide DescriptionAn 87-year-old man was referred to our hospital for chest oppression and syncope attack dueto aortic stenosis. Further examination revealed severe aortic stenosis(pressure gradient of107mmHg, aortic valve area of 0.75c㎡), ascending aortic aneurysm(60mm in diameter)andtriple-vessel disease of coronary arteries. Therefore, a surgical operation was indicatedelectively. Under cardiopulmonary bypass with normothermia, coronary artery bypass grafting(CABG)was performed. Then the aortic root and the ascending aorta were replaced with aFreestyle valve(27mm)and a woven Dacron graft(30mm Hemashield with 1branch),respectively.Duration of cardiopulmonary bypass and aortic cross-clamp was 267 and 203 minutes,respectively. Postoperative course was uneventful. On the 14th postoperative day, he underwentcoronary and graft angiography, which showed all the grafts were patent with good flow.He was successfully discharged on the 19th postoperative day. -
慢性解離性大動脈瘤の肺動脈穿破例
59巻9号(2006);View Description Hide DescriptionAortopulmonary fistula is an extremely rare complication of aortic dissection. We report acase of a chronic dissecting giant aneurysm with an aortopulmonary fistula. A 78-year-oldwoman experienced sudden onset chest pain and oppression. Chest X-ray showed ascendingaortic and left ventricular enlargement and pulmonary congestion. Computed tomography(CT)confirmed the 100mm ascending aortic aneurysm with dissection and aortopulmonary fistula.Operative repair was performed under profound hypothermic circulatory arrest with selectivecerebral perfusion. The proximal and distal end were obliterated using a gelatin-resorcinformaldehydetissue glue and reinforced with a Teflon felt circumferential strip.The ascendingaorta was replaced by a 30mm coated Dacron vascular graft and the aortopulmonary fistula wasclosed with pledgeted vertical mattress suture. Postoperative CT showed a normally functioningvascular implant without any sign of aortopulmonary shunt or pulmonary artery stenosis -
Calcified amorphous tumor(CAT)の病理診断を得た透析患者に発症した心臓内腫瘤の2例
59巻9号(2006);View Description Hide DescriptionWe report 2cases of calcified amorphous tumor(CAT)in hemodialysis patients. Case 1is a68-year-old man who had received hemodialysis for 11 years due to diabetic nephropathy withrenal failure. He was admitted because of shortness of breath. After appropriate diagnostictesting,we found a 7mm movable tumor on the side of the left atrium causing stenosis at the baseof the left anterior descending artery(LAD). We suspected this to be a myxoma. We performeda myxomectomy and coronary artery bypass grafting(CABG). The tumor had a stalk andhemogenesis on the surface. Case2is a 63-year-old man who had received continuous ambulatoryperitoneal hemodialysis for 18months due to diabetic nephropathy with renal failure. He wasadmitted because of subjective complaints of chest compression and shortness of breath.Ultrasound cardiography revealed 16mm tumor on the posterior mitral valve leaflet with mildmitral regurgitation. We removed the tumor and placed a mitral valve prosthesis. Grossly thetumor was encapsulated with endocardium.On pathological examination, both tumors were CATs. CAT is a lesion characterized bycalcified fibrin deposits. Preoperative diagnosis of these tumors is difficult. While manysurgeons elect to conservatively watch these tumors among dialysis patients, when they aremovable, there is a risk of embolism and we should remove the tumor early. -
超高齢者左室自由壁破裂の1例
59巻9号(2006);View Description Hide DescriptionWe successfully repaired left ventricular free wall rupture in a 91-year-old woman. She wasadmitted to our hospital because of consciousness loss. Blood pressure was only 60mmHg onarrival. Contrast-enhanced computed tomography (CT)demonstrated massive pericardial effusionand transmural contrast defect of the left ventricular lateral wall in the delayed phase.Upon surgery there was massive clot around the heart. A localized infracted area on the leftventricular lateral wall was exposed using off-pump coronary artery bypass (OPCAB)technique.There was mild bleeding only during diastolic phase. Three mattress sutures of3-0prolene withTeflon felt strips were placed to control the bleeding under beating heart. A sheet of collagenand fibrin glue was also applied. Postoperative course was uneventful. This type of leftventricular rupture could be less invasively repaired by off-pump technique. As far as weinvestigated, this is the oldest patient of ventricular free wall rupture successfully repaired. -
血中顆粒球コロニー刺激因子が高値を示し肺膿瘍との鑑別が困難であった肺多形癌の1例
59巻9号(2006);View Description Hide DescriptionA 52-year-old man with a history of heavy smoking was hospitalized for evaluation of fever.Pulmonary abscess was initially suspected by computed tomography (CT) showing an ovoid,well-demarcated nodule of 61mm in diameter with coarse calcification in S2a of the right lung.The patient was treated with antibiotics,but no improvement was seen in inflammatory reactionsor lesion size. Marked leukocytosis and high level of granulocyte colony stimulating factor (GCSF)was shown by laboratory examination. To improve patient condition and ensure correctdiagnosis,right upper lobectomy of the lung was performed. Pleomorphic carcinoma of the lungwas subsequently diagnosed. G-CSF producing tumor was suspected,since the normalization ofserum G-CSF level followed by the improvement of both fever and inflammatory reaction wasobserved postoperatively. We also present herein a review of 22Japanese cases of pleomorphiccarcinoma producing G-CSF of the lung, characterized by leukocytosis. -
早期気管切開下人工呼吸器管理と理学療法により保存的に治癒した外傷性動揺胸郭の1例
59巻9号(2006);View Description Hide DescriptionA 73-year-old man hit his fore-chest accidentally when he rode his motorcycle. A huge flailchest was observed on his central fore-chest, and multiple fractures of costal cartilage weresuspected. He developed pneumonia on the 4th hospital day,and he was intubated and mechanicalventilation was initiated. Because frequent sputum aspiration was necessary and aggressivephysiotherapy was desirable, a tracheotomy was performed on the same day of intubation. Herecovered from respiratory failure with conservative therapy and the mechanical ventilation wasdisconnected 13days later. Tracheotomy in the early phase of respiratory failure with flail chestwas very effective and the surgical fixation of flail segment would not be necessary even in thecase of ‘stove-in chest’like the present case. -
高分化胎児型腺癌の要素を有する淡明細胞腺癌の1例
59巻9号(2006);View Description Hide DescriptionA 69-year-old woman complaining of a cough was admitted to our hospital. Chest X-rayshowed a mass in the right lower lung field. Chest computed tomography(CT)showed a tumorwith notch, 3cm in diameter, in the right lower lobe (S-S). The tumor was diagnosed asadenocarcinoma by the biopsy under chest CT. The patient underwent right lower lobectomy(ND2a). The tumor was whitish solid mass, 35×34×29mm in size. Histopathologically, thetumor was diagnosed as clear cell adenocarcinoma with a component of well-differentiated fetaladenocarcinoma (WDFA), pT2N0M0, stage IB. The patient was discharged and receivedpostoperative chemotherapy (UFT). The patient has been doing well without any tumorrecurrence for 1year postoperatively -
気管原発炎症性筋線維芽細胞性腫瘍の1例
59巻9号(2006);View Description Hide DescriptionA 45-year-old female with a complaint of dyspnea was admitted to our hospital. Computedtomography (CT) and bronchoscopy revealed a 10mm intraluminal polypoid tumor with asmooth surface and hemorrhagic tendency located in the tracheal wall 2.0cm distal from thevocal cords. For pathological diagnosis, airway management and hemorrhage control, tumorresection was performed using a rigid bronchoscope and neodymium yttrium aluminum garnet(Nd-YAG) laser under general anesthesia. Histologically, the tumor was diagnosed as aninflammatory myofibroblastic tumor of the trachea. Inflammatory myofibroblastic tumor istypically a benign tumor that develops in such sites as the lung,stomach,and mesentery. To thebest of our knowledge, this is the first reported case of an inflammatory myofibroblastic tumorarising in the trachea.
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連載 医療の質の保証―ブリストルの遺産 (第4回)
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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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