胸部外科
Volume 62, Issue 7, 2009
Volumes & issues:
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胸部外科の指針
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蛍光画像システムによるCABG グラフトの術中評価
62巻7号(2009);View Description Hide DescriptionWe investigated the efficacy of intraoperative fluorescent imaging system for the assessment of coronary artery bypass grafting(CABG). We used SPY imaging system in 100 CABG( 57 off-pump and 43 on-pump CABG), totalling 287 distal anastomoses. The total graft patency rate on postoperative angiography in this series was 96.2%( 276/287). Graft revision was done in 10 cases( 10.0%) and 13 anastomoses( 4.5%) by SPY imaging, which all resulted in good patency at postoperative angiography. On the other hand, 7 distal anastomoses and 1 mammary graft( 2.8%) appeared to be successful on intraoperative SPY imaging, but were revealed to be occluded by postoperative angiography. SPY imaging system is useful for graft validation, and may contribute to improvement of coronary bypass graft patency.
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今月の臨床
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マルチスライスヘリカルCT を用いた胸部大血管とその分枝による気道狭窄の評価
62巻7号(2009);View Description Hide DescriptionAirway obstruction due to compression by the thoracic great vessels or their branches sometimes appears in patients with congenital heart disease. However, to make a definitive diagnosis may not be easy, because respiratory symptoms are common and stem from a variety of causes in this cohort. Thus, some invasive evaluation, including angiography, bronchial fiberscopy, and bronchography has usually been required. We employed multi-slice helical computed tomography( MSCT) and 3-dimensional (3D) image reconstruction in 7 cases (median age, 107 days;range, 21 days to 6 years) who were suspected of complicating external vascular compression as a cause of respiratory symptoms. The CT scan clearly showed detailed anatomy of the thoracic vessels and interrelationship with the airway systems. It also disclosed a culprit artery compressing the trachea or bronchus. Different from other invasive or noninvasive examination modalities, MSCT allows precise evaluation of 2 independent organ systems, such as vascular and respiratory systems. We conclude that MSCT with 3D image reconstruction represents a reliable less-invasive technique for assessment of symptomatic airway obstruction caused by vascular compression.
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今月の話題
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心房中隔欠損と肥大型心筋症を合併したNoonan 症候群
62巻7号(2009);View Description Hide DescriptionNoonan syndrome is one of the most common nonchromosomal syndromes seen in children with congenital heart disease. The major cause of death is congestive heart failure. We report a case of Noonan syndrome with hypertrophic cardiomyopathy and arterial septal defect (ASD). Since 10 years old he had been suffering from congestive heart failure. ASD patch closure with a fenestrated flap valve patch was performed at 12 years of age. After operation, left-to-right shunt flow through the patch gradually decreased and he was discharged at 19 postoperative day in good condition. -
高度石灰化大動脈を伴う大動脈弁狭窄に対する弁置換および部分弓部置換術
62巻7号(2009);View Description Hide DescriptionWe report a case of aortic valve replacement and hemiarch replacement with reconstruction of the brachiocephalic artery in a patient with a porcelain aorta. A 65-year-old man was admitted to the hospital for aortic stenosis. Computed tomography demonstrated severe aortic calcification and extensive calcification covering a wide area of the aorta. The echocardiography showed a highly calcified aortic valve and a pressure gradient of 109 mmHg across the aortic valve. At surgery, calcification of the ascending aorta was severe and involved its entire circumference. Therefore, 2 cannulae were inserted to the right axillary and right femoral arteries for extracorporeal circulation. We performed replacement of the ascending aorta and hemiarch with reconstruction of the brachiocephalic artery under circulatory arrest and antegrade cerebral perfusion, as well as aortic valve replacement with a 21 mm St. Jude Medical mechanical valve. He had no major cardiac complications during the postoperative course, and was discharged on postoperative day 33. -
遠隔転移のある縦隔非セミノーマ胚細胞性腫瘍に対する集学的治療
62巻7号(2009);View Description Hide DescriptionA mediastinal nonseminomatous germ cell tumor was completely resected after down-staging by chemotherapy despite the presence of multiple distant metastases. A 22-year-old female was admitted for superior vena cava (SVC) syndrome. Her SVC was obstructed by a large anterior mediastinal tumor;she also exhibited distant metastases on a left rib, in the liver, and multiple in the lung. The blood α-fetoprotein(AFP)level was extremely elevated to 57,530 ng/ml. Four courses of BEP therapy[ cisplatin( CDDP), bleomycin( BLM), etoposide( VP-16)]and a high dose chemotherapy followed by a peripheral blood stem cell transplantation made the tumor become smaller and effected its down-staging. Residual mediastinal tumor with an intravascular tumor in SVC was completely resected. The SVC was reconstructed by an artificial vessel graft. A mediastinal nonseminomatous germ cell tumor, even though it has multiple distant metastases, can achieve down-staging and complete resection by a chemotherapy based on scientific evidence. -
多量の肺内アスベスト小体を認めた悪性胸膜中皮腫
62巻7号(2009);View Description Hide DescriptionA 53-years-old woman was admitted to our hospital because of pleural effusion. She underwent pleural biopsy and diagnosed as mesothelioma. Right extrapleuralpneumonectomy was performed. We counted asbestos bodies in the resected lung. 443,571 asbestos bodies were counted in 1 gram of dry lung. We thought that she was heavily exposed to asbestos. Since high risk of incidence of mesothelioma is suggested among her fellow worker, special investigation is necessary for asbestos exposure.
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手術の工夫
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エコーを使用し非開胸下に切除しえた胸壁神経鞘腫
62巻7号(2009);View Description Hide DescriptionWe report a case of surgically treated chest wall schwannoma without entering the pleural space utilizing ultrasonography. A 19-year-old woman was admitted for an abnormal shadow on a routine health checkup. Roentgenologic examination of the chest showed a 2 cm left chest wall mass. Chest computed tomography revealed a heterogeneous mass with obtuse angles characteristic of a pleuralbased lesion. Under general anesthesia, the patient was placed in the right decubitous position. Chest wall ultrasonography defined a mass in the intercostal space. A 2.5 cm skin incision was made on the tumor. The tumor arising from the intercostal nerve was surgically removed without entering the pleural space. The pathological examination revealed a benign schwannoma. Postoperative course was uneventful and she discharged 2 days later. Six years later the patient is well without recurrence.
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臨床経験
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くも膜下出血を合併した外傷性大動脈解離
62巻7号(2009);View Description Hide DescriptionA 77-year-old woman was transferred as traumatic thoracic aortic dissection with subarachnoid hemorrhage soon after a traffic accident. Her consciousness was slightly compromised and cardiogenic shock was developed. Serial computed tomography (CT) scans revealed an unchanging subarachnoid hemorrhage and a progressive mediastinal hemorrhage and pericardial effusion due to traumatic type B aortic dissection. An emergency distal arch replacement was performed under cardiopulmonary bypass 4 hours after the injury. She woke up 3 days after the operation without progression of subarachnoid hemorrhage on a cerebral CT scan. She was discharged 36 days after the injury. -
先天性大動脈弁狭窄症に対するKonno 手術
62巻7号(2009);View Description Hide DescriptionTwo successful cases of Konno procedure for congenital aortic stenosis and left ventricular outflow tract obstruction(LVOTO)were reported herein. A 3-year-old child previously underwent definitive repair of complete atrioventricular septal defect. Follow-up echocardiography revealed progression of valvular aortic stenosis and subaortic tunnel stenosis. Second patient was a 30-year-old male with congenital aortic stenosis, severe LVOTO and funnel chest. Both patients underwent Konno procedure, and their postoperative courses were uneventful. The Konno procedure is effective and stenotic lesion could be enlarged sufficiently even in complex LVOTO. Especially in the patient of advanced age, care should be taken to fragility of the left ventricular muscle and coronary malperfusion caused by the procedure itself. -
急速な気管支内進展をきたした下顎骨骨肉腫肺転移
62巻7号(2009);View Description Hide DescriptionA 52-year-old woman underwent the surgical treatment for osteosarcoma of the left mandible in 2003 and was followed up afterward. She suffered from dry cough and bloody sputum, and was admitted to our hospital in April 2007. Computed tomography(CT)revealed several nodules in bilateral lung, and bronchofiberscopy showed the endobronchial tumor obstructing in the right main bronchus. The metastatic tumor progressed in the right main bronchus from the right S6 lung segment. The tumor rapidly progressed in the right bronchus in comparison with the CT findings in about 2 weeks, and the possibility of the tracheal obstruction was considered. She underwent the right middle and lower lobectomy, and the endobronchial tumor was pulled through the right main bronchus. The postoperative course was uneventful, the patient was discharged on 14th postoperative day, and the chemotherapy using cisplatin( CDDP) and adriamycin( ADR) is on-going. -
肺切除標本から偶然診断しえた早期肺リンパ脈管筋腫症
62巻7号(2009);View Description Hide DescriptionWe report a case of incipient pulmonary lymphangioleiomyomatosis (LAM) diagnosed by histopathological examination of excised lung. A 28-year-old woman was referred to our hospital because of recurrent left pneumothorax. Computed tomography showed no abnormality except for small bullae in the right middle lobe. She underwent video-assisted thoracoscopic surgery and we excised the apex of the left lung showing hypertrophic pleura. Microscopic examinations of the surgical specimen revealed multiple focal accumulations of small spindle-shaped cells stained positively with anti-HMB-45 antibody, specific for LAM. Furthermore, among these multiple lesions, vascular invasion of HMB-45 positive cells were observed, which demonstrates invasive and metastatic potential of LAM cells as previously reported. This case implicates a need for a careful pathological examination of excised specimens in female cases of surgically treated pneumothorax even though pre-operation or macroscopic examination shows no specific findings.
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症例
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偽性大動脈縮窄症に合併した遠位弓部大動脈瘤の1 例
62巻7号(2009);View Description Hide DescriptionA 20-year-old woman without any significant history of disease was referred for further investigation of an aortic arch aneurysm. The arterial blood pressure in the right arm was higher than in the left arm and in both legs. An multi-detector row computed tomography (MDCT) and an aortogram revealed narrowing of the middle aortic arch, kinking at the ligamentum arteriosum, subsequent multiple aneurysmal formation, and stenosis and narrowing of the descending aorta. The left subclavian artery branched from the 1st aneurysm. We resected the aneurysms and reconstructed the distal aortic arch and left subclavian artery using a woven polyester graft. This case was diagnosed as thoracic aortic aneurysm associated with pseudocoarctation, which is a quite rare congenital anomaly. -
左房穿破をきたした大動脈弁置換術後解離性大動脈瘤の1 例
62巻7号(2009);View Description Hide DescriptionAortocameral fistula is a rare complication of aortic dissection. We herein report a case of aortic dissection after aortic valve replacement(AVR)complicated with a fistula to the left atrium. A 76-year-old man who had undergone AVR 1 year previously, was admitted to our hospital because of facial edema and chest discomfort. On auscultation, a continuous murmur was heard at the left lower sternal border. Computed tomography revealed dissecting aneurysm of the ascending aorta and a fistula to the left atrium was suspected. Transesophageal echocardiography showed the fistula between the false lumen of the aneurysm and the left atrium. Ascending aorta replacement and closure of the fistula was performed. There was dense adhesion between the aortic root and the roof of the left atrium. It seems that postoperative adhesion plays an important role in formation of aortocameral fistula. -
肺癌精査中に発見された左房粘液腫に対する心肺同時手術の1 例
62巻7号(2009);View Description Hide DescriptionA 59-year-old woman was admitted because of an abnormal shadow on the chest X-ray film. Transbronchial lung biopsy revealed adenocarcinoma of the right lung, and chest computed tomography showed left atrial tumor. First, we performed a resection of left atrial tumor (myxoma) under cardiopulmonary bypass(CPB), followed by a right upper lobectomy with lymph node dissection. The postoperative course was uneventful, and she was discharged on the 14th postoperative day. It is safe and efficient that pulmonary resection and cardiac operation under CPB are surgically treated in a one-stage operation. -
長期生存を得ている頸部異所性胸腺腫多発転移の1 例
62巻7号(2009);View Description Hide DescriptionA 60-year-old woman presented with a palpable and painful nodule of her neck. Physical examination revealed that the anterior neck mass was enlarged without other positive findings. The tumor was not diagnosed with a fine needle aspiration biopsy, so that the excision of the tumor was underwent. The diagnosis at permanent section analysis revealed a non-invasive thymoma. The patient did not receive adjunctive postoperative therapy. For the duration of 6.5-year follow-up, metastasis of the left lobe of thyroid and right upper lobe of lung in twice have been sequentially detected and resected, and now she has been healthy with no known recurrence of the tumor. The recurrence of a non-invasive cervical ectopic thymoma has been reported as extremely rare, and this case indicates that the surgical control for recurrence lesion of cervical ectopic thymoma is effective when the tumor is resectable. -
早期悪性胸膜中皮腫の1 例
62巻7号(2009);View Description Hide DescriptionWe report a case who had undergone operation of very early malignant pleural mesothelioma( MPM). A 58-year-old woman admitted to first visited hospital because of pleural effusion of the right side. She received a diagnosis of epithelial type MPM which had been confirmed from a pleural biopsy spacemen obtained by thoracoscopy under local anesthesia. An abnormal change of the pleura could not be detected on chest X-ray and thoracic computed tomography(CT)scan after chest drainage. She was referred to our hospital for surgery, and was undergone an extrapleural pneumonectomy followed by postoperative treatment with cisplatin puls gemcitabine. Pathologically, the disease was diagnosed as stage ⅠA based on the classification of International Mesothelioma Interest Group( IMIG). There is a no evidence of the relapse 9 months after the operation. An early diagnosis of the MPM is very difficult. The thoracoscope with local anesthesia was very effective for early diagnose of a MPM.
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連載 画像診断Q&A
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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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書評
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