胸部外科
Volume 63, Issue 5, 2010
Volumes & issues:
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胸部外科の指針
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多発原発性肺癌手術例の検討
63巻5号(2010);View Description Hide DescriptionWe assessed the selection of the type of pulmonary resection, operative morbidity, mortality and theoutcome of our 14 cases who underwent surgical treatment for multiple primary lung cancer. Elevencases underwent lobectomy with limited surgery, 3 cases underwent combination of limited surgery.Only 1 case had prolonged air leakage after surgery, but other cases had no postoperative complicationand there was no operative death. The survival rate was higher than that of T4 (metastasis to thesame lung lobe) cases and M1 (metastasis to another lung lobes) cases. With this result, we considerthat postoperative good survival can be expected by the aggressive surgical approach for cases of multipleprimary lung cancer, despite it is difficult to distinguish multiple primary lung cancers and metastaticcancers preoperatively.On the other hand, the opportunity to treat early-stage lung cancer is possibly increase with thespread of medical checkup using computed tomography (CT), it will be necessary to introduce limitedsurgery at 1st operation to keep post-operative pulmonary function, considering another surgery for the2nd primary lung cancer.
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今月の臨床
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左総頸動脈術中解離による完全閉塞に対し頸動脈再建を施行したStanford A 型急性大動脈解離
63巻5号(2010);View Description Hide DescriptionWe describe a case of Stanford type A acute aortic dissection. Replacement of the ascending aortaand aortic arch was performed using an“ arch 1st technique”. Following the completion of replacement,hypotension of the left superficial temporal artery pressure was detected. Ultrasonography revealed dissectionof the left common carotid artery(LCCA)and compressive occlusion of the true lumen. Reconstructionof the LCCA was performed in the neck. The patient did well after the operation without anyneurological abnormalities.
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臨床と研究
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心膜合併切除・左房合併切除を伴う肺癌手術例の検討
63巻5号(2010);View Description Hide DescriptionWe evaluated surgical results for the patients who underwent pulmonary resection combined withpericardial or left atrial resection due to locally advanced non-small cell lung cancer (NSCLC). Sevenpatients who underwent pericardial resection (T3 group) and 4 patients who underwent resection ofthe left atrium (T4 group) were included in this study, and clinical findings and prognosis were evaluated.Eight patients underwent pneumonectomy, and others underwent lobectomy or bilobectomy. Histologyof the cancer was squamous cell carcinoma in all patinets. As for pathological node involvement, N0/N1disease was 72.7% and N2 disease was 27.3%. Induction chemotherapy was performed in 75.0% of T4group. Adjuvant chemotheraphy was performed in 71.4% of T3 group and 75.0% of T4 group. Fiveyear-survival was 57.1% in T3 group and 25.0% in T4 group. Five-year-survival was 62.5% in N0/N1disease and 0% in N2 disease. Statistical significance in prognosis was seen in lymph node status(p=0.0317). Extended resection of pericardium or left atrium for patients with N2 disease of NSCLC isnot recommended. When invasion to pericardium or left atrium is diagnosed during surgery, extendedresection should be indicated in patient without N2 metastasis.
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手術の工夫
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横隔膜交通症の手術における気腹法を用いた欠損孔の同定
63巻5号(2010);View Description Hide DescriptionA 53-year-old male was admitted to our hospital because of dyspnea. Chest radiograph showed a massiveright-sided hydrothorax. He was suffering from chronic renal failure and had undergone continuousambulatory peritoneal dialysis( CAPD) for 8 months. The diagnosis of pleuroperitoneal communication(PPC) was made using injection of indigocarmine into the peritoneal cavity with subsequent pleuraldetection by thoracocentesis. Injection of contrast media into the peritoneal cavity showed a domeshaped radio-opaque shadow which is located on the diaphragmatic dome followed by the movement ofcontrast media into the thoracic cavity. Video-assisted thoracic surgery( VATS) was performed undergeneral anesthesia. To identify the point of communication, the method of detecting air leakage wasemployed. A bleb like lesion on which the hole existed was observed at the center of the diaphragm,and air leakage was identified by filling the thoracic cavity with saline. The pressure in the peritonealcavity was maintained at 10 mmHg by continuous CO2 inflation. Direct closure was performed to repairthe PPC, which succesfully stopped the air leakage. CAPD could be restarted immediately aftersurgery. No recurrence of hydrothorax has been detected for more than 14 months after surgery. -
ミニループリトラクターを用いた1 ポート胸腔鏡下自然気胸手術
63巻5号(2010);View Description Hide DescriptionWe successfully performed 1-port video-assisted thoracic surgery (VATS) for primary spontaneouspneumothorax using Mini Loop RetractorII in 137( 39%) of 351 patients from March 2005 to May 2009at Tokyo Teishin Hospital. This retractor is accessible to the thoracic cavity by simple skin puncture.It can hold and retract the lung freely like forceps. We made a 2 cm incision and inserted a 5 mm thoracoscope.We held the affected lung by the retractor and performed wedge resection by endoscopicstaplers through skin incision. The operation time was 34.8±10.9 minutes and the blood loss was tracelevel in all cases. The duration of chest drainage was 1.2±0.8 days and the postoperative hospital staywas 2.8±1.2 days. There was no major complications. The recurrence of pneumothorax was noted in17( 12.4%) cases. One-port VATS for pneumothorax using Mini Loop RetractorII can be applied easilyand safely to selected patients.
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臨床経験
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急性心外膜炎を契機として発見された胸腺肉腫様癌
63巻5号(2010);View Description Hide DescriptionThymic carcinoma is rare. Particularly sarcomatoid carcinoma of the thymus is a very rare disease;it has been reported in only 15 patients to date. The prognosis is very poor and diagnosis and treatmenthave not yet been established.We report a case of 63-year-old man who was initially diagnosed with acute pericarditis and wasfinally found to be sarcomatoid carcinoma of the thymus. He underwent surgery and the tumor wascompletely resected. However, 6 months after surgery, local recurrence was noted. The patient wastreated by radiotherapy followed by paclitaxel monotherapy. Partial remission was achieved transientlywith paclitaxel, but the tumor again recurred. He died 33 months after surgery.The possibility of diseases like this tumor must be kept in mind for a patient with chest symptoms.Paclitaxel monotherapy is likely to be effective in treating sarcomatoid carcinoma of the thymus. -
既製Y 型グラフトで再建を行った上大静脈浸潤胸腺癌
63巻5号(2010);View Description Hide DescriptionA 57-year-old woman was admitted to our hospital with a complaint of left supraclavicular lymphnode’s swelling in January 2007. Computed tomography( CT) showed the lobulated tumor suspected ofsuperior vena cava (SVC) invasion, located in the anterior mediastinum, 5×3 cm in size. The patientunderwent thymectomy, resection of SVC, and partial resection of the right upper lobe. SVC was reconstructedby ready-made Y-graft (Hemashied φ18×9 mm). Histopathological diagnosis was thymiccancer, poorly differentiated squamous cell carcinoma. The patient was discharged on 21st postoperativeday. Postoperative radiotherapy (RT:12.6 Gy) was canceled for the side effect. Alternatively,adjuvant chemotherapy [carboplatin (CBDCA) +paclitaxel (PTX)] was administered. Additional RT(50 Gy) was given to the lesion of local recurrence 1 and half year after the operation. The patient wasalive without any signs of recurrence after RT. Left side bypass graft was patent at 8 months postoperatively,but was obliterated thereafter. Right side bypass is patent at more than 2 years postoperatively.Ready-made Y-graft can be one of the choices of SVC reconstruction. -
重症筋無力症合併胸腺腫術後に発症した赤芽球癆
63巻5号(2010);View Description Hide DescriptionA 73 year-old woman was diagnosed as thymoma with myasthenia gravis (MG)[ocular type] 18years ago, but she rejected surgical treatment. The remission of myasthenia gravis has been obtainedby treatment of medication. This time, to avoid myasthenic crisis at the time of orthopedic surgery, sheunderwent surgical treatment for thymoma:extended-thymectomy, resection of the left brachiocephalicvein and reconstraction using ringed polytetrafluoroethylene (ePTFE) graft. Pathologic diagnosis wasMasaoka stage Ⅲ thymoma and World Health Organization (WHO) type B2+B3. After orthopedicsurgery, irradiation was performed for mediastinum. During this period from the resection of thymomato irradiation, she developed gradually progressive anemia, and as a result of bone marrow examination, she was diagnosed as pure red cell aplasia (PRCA). PRCA has improved with immunosuppressivetreatment. One year have passed with no recurrence of thymoma and PRCA. -
経皮的肝生検による穿刺経路播種が疑われた肝細胞癌の胸壁転移
63巻5号(2010);View Description Hide DescriptionWe reported a case of hepatocellular carcinoma (HCC) with needle tract implantation of the rightthoracic wall, which were strongly suspected to have been caused by percutaneous needle biopsyperformed at the former hospital to diagnose HCC in September 2001. He visited our hospital at his ageof 68 and underwent transcatheter arterial embolization in February 2002. In November 2007, a right9th intercostal tumor measuring 20×15 mm was found on his computed tomography (CT) scan. Heunderwent resection of the right thoracic wall tumor in January 2008. Pathological diagnosis of thetumor was well differentiated HCC. Twenty one months after surgery, he remains alive without recurrence. -
多発肺アミロイド結節を伴う胸腺MALT リンパ腫
63巻5号(2010);View Description Hide DescriptionHere, we present a case of mucosa-associated lymphoid tissue( MALT) lymphoma in the thymus withmultiple amyloid nodules in both lung. A 66-year-old woman was incidentally found to have an abnormalshadow on mass-screening chest roentgenogram.A chest computed tomography (CT) demonstrated a mass of 50 mm in diameter with a smoothmargin adjacent to the heart in the anterior mediastinum and multiple small nodules in both lung. As adifferential diagnosis, thymic carcinoma with multiple lung metastases was firstly considered from theseclinical informations. To make a definite diagnosis, the operation via a thoracoscopy was done. As aresult, it turned out that pulmonary nodules were amyloidosis and the thymic tumor was MALTlymphoma. Postoperative course was uneventful and she was treated with chemoradiotherapy. Inaddition, she was diagnosed with Sjögren’s syndrome 1 and half years later. Four years later the patienthas been well without recurrence.
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症例
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3C(cranio-cerebello-cardiac)症候群を伴った心室中隔欠損,肺高血圧症の1 例
63巻5号(2010);View Description Hide DescriptionWe report a case with the rare association of craniofacial anomalies, cerebellar vermis hypoplasia(Dandy-Walker variant) and congenital heart disease referred to as 3C(cranio-cerebello-cardiac) syndrome.A male infant was born at 40 weeks’ gestation. The birth weight was 2,896 g. At birth he hadmacrocephaly, widely open metopic suture, ocular hypertelorism, cleft palate, apparently low-set ears,cerebellar vermis hypoplasia and ventricular septal defect (VSD) with pulmonary hypertension. Chromosomeswere normal and we diagnosed 3C syndrome. At 8 months of age we performed a cardiaccatheterization. The pulmonary artery pressure was 70/26 (48) mmHg and pulmonary vascular resistance(RpU) was 8.5 U/m2. But under the oxygenation RpU decreased to 1.5 U/m2. At 10 months ofage we performed VSD patch closure. After operation his pulmonary artery pressure was 39/13 (25)mmHg under the oxygen therapy. He was on good course and discharged at 58 post operative day. -
Stanford B 型急性大動脈解離破裂と術前診断した特発性胸部大動脈破裂の1 例
63巻5号(2010);View Description Hide DescriptionBackground:Spontaneous rupture of the thoracic aorta is extremely rare. It is very difficult to diagnoseit preoperatively.Case:A 71-year-old woman suffered the sudden onset of severe chest and back pain and was admittedto our hospital. Enhanced computed tomography( CT) showed mediastinal hematoma and apparentaortic dissection in the aortic arch and descending aorta. We diagnosed the rupture of Stanford type Bdissection and performed an emergency operation. 20 mm tear was found in the intima of lesser curvatureof aortic arch and 5 mm perforation was found in the adventitia of this part. There was no flap orfalse lumen suggestive of a dissection nor was there aortic aneurysm. Total aortic arch replacementwas performed.Result:The surgery was followed by an uneventful postoperative course.Conclusion:A case of spontaneous rupture of the thoracic aorta which was diagnosed the rupture ofStanford type B dissection preoperatively was successfully treated. -
手術および放射線治療が奏効した進行胸腺癌の1 例
63巻5号(2010);View Description Hide DescriptionThymic carcinomas are rare neoplasms, and standard treatment has not yet been established. Wereported a case of advanced thymic carcinoma effectively treated by surgical resection and postoperativeradiation therapy. A 71-year-old man was pointed out an abnormal shadow on chest X-ray. Chestcomputed tomography (CT) scan demonstrated an anterior mediastinal tumor. The tumor was diagnosedas carcinoma by CT-guided tumor biopsy and was extirpated completely with combined partialresection of the left lung. Microscopically, the tumor was diagnosed as thymic carcinoma with directinvasion to the left lung. Following postoperative radiation therapy, the patient is doing well withoutapparent recurrence 5 years after surgery. -
明らかな増大を認めた肺過誤腫の1 例
63巻5号(2010);View Description Hide DescriptionA 72-year-old man was admitted to our hospital due to abnormal shadow in the right hilum by aroutine chest X-ray. When we had another look at a chest X-ray that had been taken 6 years before, wehad found a pulmonary nodule of 18 mm in size. The chest X-ray and computed tomography (CT)taken at admission showed a round nodule with calcification in the same site, with increasing in size to30 mm. The tumor could not be clinically diagnosed and the surgery was scheduled because the nodulehad grown and the possibility of a malignant tumor was suggested. At surgery, the tumor was easilyenucleated and the pathological diagnosis was chondromatous hamartoma. Although pulmonary hamartomais a benign tumor, operation should be performed when the tumor had grown. -
胸腔鏡下手術を行った肺孤立性毛細血管腫の1 例
63巻5号(2010);View Description Hide DescriptionWe report a case of pulmonary solitary capillary hemangioma of 59-year-old woman who visited ourhospital for an abnormal chest shadow. She had no symptoms, but a computed tomography (CT)revealed a small irregular nodule at the periphery of right S9. Early lung cancer was suspected.Video-assisted thoracic surgery (VATS) was performed for the difinitive diagnosis and treatment inJanuary, 2008. Macroscopically, the nodule showed ill defined margin and irregular in shape. Partialresection of the lung was performed and the histopathological diagnosis was solitary capillary hemangioma.Postoperative course was uneventful and there is no signs of recurrence. -
前縦隔原発巨大脂肪腫の1 例
63巻5号(2010);View Description Hide DescriptionWe report a case of anterior mediastinal lipoma. A 71-year-old female was admitted for cough. A fatdensity tumor from anterior mediastinum to left thoracic cavity was found by chest X-ray, chestcomputed tomography (CT) and magnetic resonance imaging (MRI). Defect of left dorsal diaphragmwas suspected and there was a possibility that the tumor was connected to retroperitoneum.Under the preoperative diagnosis of a benign huge mediastinal lipoma, we conducted an operation. At1st, we observed by thoracoscopy and made sure that the mass was primary anterior mediastinal tumorand not connected to retroperitoneum. Through the median sternotomy, we completely resected thetumor with thymus. The tumor showed 27 cm in diameter, and histopathological diagnosis of the tumorwas benign lipoma.Lipoma of the mediastinum is very rare and about 0.3% of all mediastinal tumors. It is sometimesdifficult to distinguish huge lipoma from liposarcoma only by clinical examinations such as CT scan orMRI. We evaluated the condition of the tumor by thoracoscopic observation, and the tumor was safelyand completely resected by median sternotomy.
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連載 ●知っておきたい文献管理のコツ(第1回:新連載)●
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これからの文献管理法―検索および収集
63巻5号(2010);View Description Hide DescriptionThe development of digitalizing technology and the Internet has enabled medical doctors andresearchers in medicine to search and read the latest articles at their desk without visiting a library. Asa result of the time and effort spent for searching articles can be extremely reduced by learning how touse effective tools in combination, the time for the research activity will certainly be greatly saved. It ispromising that the advancement of science database, online journals, evaluating system of the journalimpact will be great help for researchers.
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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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画像診断Q&A
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胸部外科医の散歩道
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書評
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