胸部外科
Volume 64, Issue 3, 2011
Volumes & issues:
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胸部外科の指針
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心臓外科手術後の心房細動に対するamiodarone の予防的投与
64巻3号(2011);View Description Hide DescriptionWe investigated the effect of amiodarone on prevention of post-operative atrial fibrillation (POAF)after cardiac surgery. Thirty cases of amiodarone (AMD) group including elective coronary arterybypass grafting and valve operation were enrolled from January 2007 to January 2010. The control( C)group consisted of 45 cases treated before 2007. Amiodarone was administered orally for the total of 14days;400 mg 7 days before the surgery, and a half dose after the surgery. POAF occurred significantlyless in AMD group( 4/30:13.3%) than in C group( 13/45:28.9%)[ p=0.029].With regard to duration of POAF, that of AMD group was significantly shorter than that of C group(16.0 hours vs 40.23 hours:p=0.018). This research suggested that amiodarone might be effective inpreventing POAF.
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今月の臨床
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大細胞神経内分泌癌手術例
64巻3号(2011);View Description Hide DescriptionLarge cell neuroendocrine carcinoma (LCNEC) is a relatively rare tumor in malignant lung neoplasms.The prognosis of LCNEC is poor and there is no consensus on the treatment for LCNEC. Wereport our retrospective assessment of 11 patients of LCNEC from 1999 to 2008. Three of 11 patientshad malignant exudate at thoracotomy. Seven patients received limited resection. There was a recurrenceeven after complete surgical resection in its early stage. Four patients received platinum-basedchemotherapy for adjuvant therapy or recurrence. The response to platinum-based chemotherapy wasrelatively good and may be comparable to that of small cell lung cancer. The overall 5-year survivalrate was 30.3%. Pulmonary LCNEC represents an aggressive tumor and multimodal treatment isrequired.
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今月の話題
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左血胸を合併した右房破裂
64巻3号(2011);View Description Hide DescriptionA 71-year-old female fell down the stairs, hit the right chest and was admitted to our hospital withright chest pain. Computed tomography revealed cardiac effusion and left hemothorax due to traumaticcardiac injury. She underwent emergency operation. Median sternotomy revealed a lot of clot and no acute bleeding. However, severe bleeding started assoon as the clot was removed. The right atrium was teared by 7 cm at the site parallel to the right coronaryartery. While the cardiac injury was covered with the operator’s hand, cardiopulmonary bypasswas established. The injury was sutured with an aid of the heart positioner to achieve complete hemostasis.Successful repair of rupture of the right atrium was reported. -
腹部大動脈瘤術後の致死的コレステロール塞栓症
64巻3号(2011);View Description Hide DescriptionA 70-year-old man underwent graft replacement for infrarenal abdominal aortic aneurysm, 50 mm indiameter. Postoperatively, he suffered from bilateral lower extremital ischemia. Although he underwentemergency embolectomy of both legs under general anesthesia, severe purplish discoloration of thedistal lower extremities developed, and acute renal dysfunction occured. He was diagnosed with cholesterolcrystal embolization syndrome (CCE). We initiated intravenous steroid therapy and infused prostagrandinintraarterially and conducted low density lipoprotein (LDL) apheresis. However, his renalfunction did not improve and his bilateral toes became necrotic completely. Multiple organ failure rapidlyworsened and he died at 38 days after surgery. CCE complicated with severe renal dysfunction is alethal iatrogenic complication after surgery for abdominal aortic aneurysm. Because the number of CCEis likely to increase in the near future, we should study about CCE more seriously. -
右側大動脈弓に合併した左鎖骨下動脈瘤と左肺癌に対する一期的手術
64巻3号(2011);View Description Hide DescriptionA 69-year-old man with right aortic arch was diagnosed as having left lung cancer (cT2aN1M0,cStage ⅡA) and an aneurysm of an aberrant left subclavian artery. The aneurysm measured 36 mm indiameter and was located 1 cm peripheral from the origin in the area known as“ Kommerell’s diverticulum”.Left carotid artery-to-left subclavian artery bypass graft was placed through a left supraclavicularincision prior to thoracotomy. This bypass graft effectively prevented neurological and ischemic complicationsof the brain and left upper extremity while we safely and successfully performed resection of theaneurysm along with radical surgery for left lung cancer through left thoracotomy.There have been only 10 case reports, including the present case, that have described surgical resectionof lung cancer in a patient with right aortic arch.In addition, this is the 1st report to describe simultaneous surgery for both left lung cancer and ananeurysm of an aberrant left subclavian artery in a patient with right aortic arch.
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手術の工夫
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癌化学療法後に発症した僧帽弁輪・左房後壁の破壊を伴う感染性心内膜炎
64巻3号(2011);View Description Hide DescriptionThe case is reported of a 48-year-old man who underwent distal pancreatectomy, splenectomy, and 4cycles of postoperative chemotherapy for stage I pancreatic cancer, at the age of 47. Four days aftercompletion of chemotherapy, the patient developed high-grade fever( 40 ℃). In addition, on day 10, hedeveloped disturbance of consciousness, followed by symptoms of shock, which led to emergency hospitalization.On day 4 of admission, the patient was diagnosed as having infective endocarditis and severemitral valve insufficiency, and was started on antibiotic and heart failure therapy. Surgery was performedon day 16 of admission;the mitral valve infection had spread to the valve cusp and ring, andthence to the posterior wall of the left atrium. After excision of the lesions, the patient underwentmitral valve replacement with a collared prosthesis valve and a translocation procedure. The postoperativecourse was uneventful, and there has been no recurrence of inflammation or paraprosthetic leakageover the year and 6 months since the operation.
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術前・術後管理
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標準的心臓血管外科手術におけるスーチャーセットの導入
64巻3号(2011);View Description Hide DescriptionA packing system for threads and needles has been introduced with the aim of efficient operations inthe field of cardiovascular surgery. To provide competent and safe surgery to patients, a suture set wasdeveloped according to the standard cardiovascular surgery procedure with cooperation between doctorsand nurses at Kochi University Hospital. This suture set was introduced to all surgeries for adultsconducted under cardiopulmonary bypass. Herein, we describe problems before the introduction, theprocess of the introduction, and designs of the suture set. In addition, we assessed the present conditionsince the introduction of this suture set. Many positive opinions were obtained from both doctors andnurses, and the suture set thus yielded a satisfactory assessment. Psychological stability and safety providedby the suture set may lead not only to cost reduction but also to an increased level of surgery as awhole. In addition, it may now be possible to provide simpler and more efficient cardiovascular surgerywith this set. This suture set will serve as a useful model for thread and needle packing systems to bedeveloped at various facilities in the future. -
体外設置型補助人工心臓装着患者の外泊支援
64巻3号(2011);View Description Hide DescriptionA 19-year-old woman suffered from fulminant myocarditis by Mycoplasma infection, and intra-aorticballoon pumping( IABP) and percutaneous cardiopulmonary suppor( PCPS) were initiated. As the cardiacfunction was not recovered, the ventricular assist device (VAS) was implanted. Rehabilitationtraining was started such as maintaining standing position at the bedside, and walking. The preparatorytraining program for homecoming was conducted twice with VAS. She strongly hoped for participationof coming-of-age ceremony in Tachikawa City that is 3 hours’ drive from our hospital. The patientstayed 1 night at home with a doctor and a medical engineer. There was no adverse event. In Japan,the community support of patients with VAS is not yet established and we hope that our experiencewill be of some help in supporting the homecoming of patients with VAS.
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臨床経験
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多発性塞栓を伴う浮遊性下行大動脈内腫瘤
64巻3号(2011);View Description Hide DescriptionA 46-year-old man was referred to our hospital for abdominal pain. Computed tomography (CT)revealed mobile mass in the descending aorta and multiple systemic embolism. Emergent operation wasindicated. Under femoral vein to femoral artery bypass, removal of mobile mass was performed. Weresected the mass with stem including aortic wall and closed the aortic defect with the pericardialpatch. Postoperative course was uneventful. Histopathology of the mass was organized thrombus withinflammatory change. -
3 種類の人工弁機能不全をきたした僧帽弁置換術
64巻3号(2011);View Description Hide DescriptionThere are 2 major types of prosthetic valve replacement complications;structural valvular deteriorationand nonstructural dysfunction. Nonstructural dysfunction includes valve thrombosis, paravalvularleak, prosthetic valve endocarditis and bleeding event. Primary tissue failure is the most common reasonfor mitral valve replacement( MVR) with tissue valves, and paravalvular leak is also a common factorof MVR in repeated MVR cases.We report a case of a woman who has undergone MVR for four times. She underwent the 1st MVRwith a tissue valve 19 years ago because of mitral valve regurgitation. Nine years after the initial operation,structural valvular deterioration developed and she underwent the 2nd MVR with a mechanicalprosthesis. Two years after the 2nd operation, she underwent the 3rd MVR because of repeated prostheticvalve thrombosis. Paravalvular leak was recognized 8 years after the 3rd operation and sheunderwent the 4th MVR. Her postoperative course was uneventful. -
抗酸菌による炎症性結節近傍に出現したAspergillus 合併肺癌
64巻3号(2011);View Description Hide DescriptionA 66-year-old man was admitted to our hospital to examine abnormal shadow in the right lung in May2009. Chest computed tomography (CT) showed a nodule in the apex of right lung adjacent to the oldshadow which was thought to be inflammatory and had been followed up since November 2002. Fluorodeoxyglucose-positron emission tomography( FDG-PET) showed significant accumulation of the isotopein the new nodule. Lung cancer was strongly suspected and the nodule with the joining lesion was surgicallyremoved. Pathological examination revealed poorly to well differentiated papillary adenocarcinomain the cancer lesion and aspergillosis in the necrotic and old fibrocaseous lesion. In the presentcase, lung cancer is thought to develop adjacent to the pulmonary aspergillosis. -
若年者に発生した肺腺癌
64巻3号(2011);View Description Hide DescriptionWe report a case of 24-year-old young man with lung adenocarcinoma. The patient had been treatedmalignant lymphoma when he was 5 years old. The patient was pointed out a tumor shadow of theright lung at his 2008 health check, but he did not receive further examination. He was again pointedout a same tumor at his 2009 health check. Plain chest computed tomography (CT) revealed a nodulein S8 of right lung. A diagnosis of lung adenocarcinoma was established by the cytology specimensobtained with bronchoscopic examination. The patient underwent right lower lobectomy with systematiclymph node dissection. Pathological stage was pT2N2M0 stage ⅢA.Lung cancer patients aged under 30 years old are rare. Lung cancer should be considered even inyoung patients with abnormal chest shadows.
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症例
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胸郭変形ならびに上行大動脈石灰化例に対する体外循環使用心拍動下再CABG の1 例
64巻3号(2011);View Description Hide DescriptionA 79-year-old post-thoracoplasty patient who had undergone coronary artery bypass grafting( CABG)20 years before was admitted to our hospital because of chest pain. Coronary angiogram showed occlusion of the both saphenous vein grafts. And the computed tomography revealed severe calcification ofthe ascending aorta. We performed on-pump beating CABG cannulating his femoral vessels and anastomosedbilateral internal thoracic artery grafts without manipulation of the ascending aorta. On-pumpbeating CABG is useful for the patients with past medical history of CABG. -
Fallot 四徴症根治術後,ePTFE に形成した異所性骨組織により肺動脈弁置換術を要した1 例
64巻3号(2011);View Description Hide DescriptionOperative correction of tetralogy of Fallot has been performed for more than 50 years and well established.To date, the literature on reoperation has focused and indications and the long-term outcomehave not been well defined. We herein report a case of pulmonary valve replacement due to ectopic ossification on expanded polytetrafluoroethylene (ePTFE) cusp in a female child who had undergoneright ventricular outflow tract reconstruction for tetralogy of Fallot with pulmonary atresia. Because ofsevere right ventricular dilatation with end diastolic volume of 186 ml/m2 on cardiac catheterization,redo operation was planned for functional recovery of the right ventricle.Previous transannlar patch was removed and pulmonary valve replacement was performed using CEP23 mm. A hard calcification was observed around the cusp of transannular patch. Pathological findingsrevealed ectopic ossification with osteoblast colonization around the ePTFE cusp. This is the 1st reportof ectopic ossification on ePTFE. -
肺癌との鑑別を要した肺放線菌症の1 例
64巻3号(2011);View Description Hide DescriptionA 57-year-old man had been observed a mass-like shadow on a chest radiograph. One year later,chest computed tomography( CT) revealed the enlargement of the shadow. Positive finding of fluorodeoxyglucose-positron emission tomography (FDG-PET) suspected lung cancer, and lingular segmentectomywas performed. The pathological diagnosis was pulmonary actinomycosis. It is necessary to considerpulmonary actinomycosis is a differential diagnosis of lung cancer. -
肺浸潤による咳嗽で発見された胸腺腫の1 例
64巻3号(2011);View Description Hide DescriptionA 83-year-old female was referred to our hospital for investigation of a persistent cough. A chestX-ray showed enlargement of the mediastinum. Computed tomography of the chest showed an anteriormediastinal mass with a maximal diameter of 6.5 cm, which had invasion to the lung. The patient underwentthymothymectomy combined resections of the lung, pericardium, and left innominate vein througha median sternotomy. Histological examination of the resected tumor revealed a World Health Organization(WHO) classification type B3 thymoma with infiltration into the lung. There were no infiltrationsof the tumor into the pericardium and the innominate vein. A persistent cough disappeared aftersurgery. No adjuvant chemotherapy was performed. She is still free from disease with a follow-upperiod of 4 months. We report a rare case of thymoma detected with a persistent cough derived frompulmonary invasion.
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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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Single coronary の大動脈弁閉鎖不全(AR)に対する自己肺動脈弁大動脈弁位移植およびヒト凍結肺動脈弁肺動脈弁位移植術(Ross 手術)
64巻3号(2011);View Description Hide Description
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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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