胸部外科

We evaluated the validity of the SOFT COAG electrosurgical output system for the treatment ofspontaneous pneumothorax. From April 2008 to May 2010, we compared 64 patients who had undergonebullae resection using endoscopic linear staplers, to 20 patients subjected to electroablation of thebullae using the SOFT COAG output system. There was no significant difference between the 2 groupsin terms of operation time, bleeding, and mean duration of postoperative chest tube drainage. Postoperativerecurrence was apparent in 3 cases for the linear stapler, and in 2 cases for SOFT COAG. Electroablationusing the SOFT COAG output system was suggested to be valid for treatment of spontaneouspneumothorax.

We hypothesized that apical bullae recurred due to the dead space problem after apical bullectomyand caused recurrent pneumothorax.Apical tenting with a large polyglycolic acid （PGA）［15×15 cm］ sheet was performed to attenuateover-expansion of the apical lung after bullectomy in the 43 patients （37 men and 6 women） with primaryspontaneous pneumothorax. Shrinkage of the apical lung was estimated by measurement of thedistance between the lower edge of the 1st rib and the apex on the chest radiography and computedtomography. Shrinkage was 9.22（ 0〜24） mm on the 10th postoperative day and 7.76（ 2〜17） mm at 3months after surgery. Bullous formation recurred in 7 apical lungs of 6 patients. Minimal pneumothorax,which resolved with no treatment recurred in 3 patients. Thoracic drainage for recurrent pneumothoraxwas required in 1 patient. The degree of shrinkage at 3 months after bullectomy was not correlatedto recurrent bullous formation, but correlated to recurrent pneumothorax. These data suggestedthat apical tenting method with a PGA sheet can reduce the recurrence rate of the pneumothorax afterbullectomy, while it can not inhibit recurrent bullous formation.

Background：Pneumothorax in middle-aged and elderly patients has various different features fromyoung patients. We set out to investigate the outcome and usefulness of video-assisted thoracic surgery（VATS） in this group.Patients and methods：From January 1993 to August 2010, 168 patients underwent a total of 178 thoracoscopicsurgeries. There were 160 men and 8 women with mean age of 67 （range, 50 to 85）. Theaverage duration of thoracic drainage before surgery was 7.4 days. We excised only responsible lesionsas minimum degree of dissection as possible. When patients have intractable air leakage and chest computedtomography（ CT） indicates severe pleural adhesions, pleurography should be performed to locatethe site of air leakage and determine surgical approaches. One hundred and seventy patients weretreated with the lateral approach, while 8 patients were successfully treated with the anterior approach.One hundred and fifty-one patients were treated with VATS alone, and 27 patients were treated withthe combination of VATS and small thoracotomy. The duration of chest tube drainage, hospital stay,post-operative complication, outcome and recurrence were assessed.Results：The air leakages stopped and all patients except for 2 patents were discharged withoutdrainage tubes. Postoperative drainage time was 4.5±3.4 days. Postoperative hospital stay was 9.9±13.9 days. One patient died caused by perioperative myocardial infarction. Seventeen patients died ofother diseases. Seven patients needed local hospital treatments and the recurrence rate was 3.9％.Conclusion：VATS for pneumothorax in patients over 50 years old is very useful by appropriate perioperativemanagements.

Contralateral pneumothorax is one of severe complications after lung resection. We present our experienceswith surgical treatment of 5 cases ［case 4 is under the percutaneous cardiopulmonary support（PCPS） assistance］ of contralateral pneumothorax after lung resection. All cases were men and notable to stop smoking, the disease caused by lung resection was lung cancer 3 and tuberculosis 2. Operativeprocedure was lobectomy 4 and pneumonectomy 1.Tracheal intubation was done before radiological confirmation of pneumothorax in 4 cases. Immediatelyafter diagnosis all patients underwent chest drainage. Because the contralateral pneumothoraxafter lung resection is severe complication, we thought that surgical treatment is necessary. Thoughthe thoracoscopic surgery under the PCPS assistance is also possible, it seems that a small thoracotomywith adjusting ventilation by anesthetist are more favorable. Accurate diagnosis and treatment is thekey for success of treatment. The patient who receives lung resection due to lung cancer often hasemphysema, and the risk of contralateral pneumothorax after the operation should also be explained.

From May 2005 to October 2010, 9 patients with severe emphysematous bullae suffered from uncontrolledpneumothorax had been successfully treated by a new surgical method in our hospital. By usingdirect instillation of fibrin glue into the ruptured bulla following ligation of the ruptured bulla hole, 8 of 9patients revealed no recurrence of new rupture and pneumothorax.Although the ligation of ruptured bulla hole tended to increase tension of surface of the bulla aroundthe ligation and caused new rupture of the bulla, the fully instilled glue reduced intra air pressure of theligated bulla and prevented new rupture. Additionally, the direct instillation of the glue immediatelystopped the air leakage by itself.This direct instillation method of the glue encouraged us to challenge the surgery for the patients sufferedfrom uncontrolled pneumothorax with severe emphysematous bullae.

Secondary spontaneous pneumothorax（ SSP） such as lymphangioleiomyomatosis（ LAM）, bronchiolitisobliterans（ BO） is intractable or repeated the recurrence of pneumothorax. The most effective chemicalpleurodesis for intractable pneumothorax is talc poudrage and so on that is associated with a reductionin the rate of pneumothorax recurrence. However, severe and broad pleural adhesion due to the pleuralinterventional procedures sometimes cause serious bleeding when the patients undergo lung transplantation.We must be considerd for new approaches to these intractable secondary pneumothoraces whichreplaced traditional conservative and surgical approaches. We had proposed new 2 approaches of totalpleural covering （TPC） and awake surgical intervention （ASI） for intractable pneumothorax. Weapplied the TPC modified with coverage of air leak points with polyglycolic acid （PGA） sheet to 5patients with intractable bilateral pneumothorax to reduce the risk of excessive bleeding by chemicalpleurodesis in lung transplantation. The bilateral pneumothorax was well controlled, and no recurrencehas been observed. TPC is reliable procedure for management intractable bilateral SSP.For 12 high-risk patients with other underling pulmonary diseases on general poor conditions, a surgicalintervention was performed in awake condition. The air leaks were stopped in 11 cases except for 1case. The recurrence of pneumothorax after surgery was 2 cases. ASI for intractable secondary pneumothoraxcan be applicable to selected patients with deteriorated general condition.

The thoracoscopic surgery for patient with pneumothorax has been considered to be safe and easy.In recent years, there is a growing number of secondary pneumothorax due to advanced pulmonaryemphysema in elderly patients. To confirm the existence of adhesion and the site of air leakage areimportant prior to surgery. In our institution, thoracography was performed before surgery in 9 casesof emphysema and secondary pneumothorax over 60 years old patients. The mean age was 72.2 yearsold and all patients were male. Air leakage and its site could be identified in 6 cases by thoracography.In the remaining 3 cases, adhesion sites were identified. There were no complications in all cases. Theoperation time was 117 minutes, and blood loss was 9.9 ml in average. The mean postoperative drainageperiod was 1.6 days and total hospital stay was 5.9 days. We conclude that the thoracoscopic surgerycan be performed more safely by obtaining information of thoracic cavity using thoracography beforesurgery.

Surgical treatment for secondary pneumothorax in elderly patients is very difficult because of havinga high perioperative risk related to the presence of underlying chronic lung disease.In this study, we performed a retrospective review of elderly （≧ 70 years old） 35 patients with secondarypneumothorax who underwent surgical treatment between 2000 and 2009. Of the 35 patients, 31were men and 4 were women with an average age 77.9 years old. Seventeen patients of them hadalready received oxygen therapy. They were not only in chronic respiratory failure but also malnutrition.Hospital mortality rate was 14.3％. Three patients died within 30 postoperative days and 2 patientswere with hospital death after operation. The 5-year survival rate in patients with secondary pneumothoraxwas 41.7％. Although secondary pneumothorax is one of benign pulmonary diseases, its prognosisin elderly patients is poor.In conclusion, prompt diagnosis and treatment of secondary pneumothorax in elderly patients aremandatory. They could improve the outcome of this disease.

Thoracoscopic surgery under epidural and local anesthesia for intractable pneumothorax were performedin 26 patients. A total of 29 thoracoscopic operation were performed in 26 patients. Twentythreepatients undervent only a single thoracoscopic operation, and 3 patients underwent twice thoracoscopicoperations. We could control the air leak of intractable pneumothorax with the covering ofpolyglycolic acid sheets using aerosolized fibrin glue in 25 patients. In all patients postoperative coursewas uneventful and there was no operative death.

Intractable pneumothorax with interstitial pneumonia （IP） is famous for the disease finally to lead todeath in case of persistent air leakage. It is because severe infection, respiratory insufficiency and tissuehealing insufficiency by treatments with steroid hormones and immune-suppressants on IP.Pleurodesis is generally performed although the effect of it is questionable. It is important to stopimmune-suppressants and reduce steroid hormones before the treatments to succeed in thoracoscopicsurgery and thoracographic fibrin glue sealing method（ TGF） if possible.Less invasive interventional treatments like TGF are recommendable because intractable pneumothoraxwith IP is in the high risk group to need to avoid surgery. Hand suturing, looping, covering and puttingTachoComb on the air leak point instead of end-stapling should be performed in order to stop airleakage when forced to choose thoracoscopic surgery.

We performed a retrospective review of 9 patients who underwent intracavity drainage under localanesthesia for emphysematous bulla and infected bulla between 1996 and 2010. Three patients withgiant emphysematous bulla were treated intracavity drainage. Pneumothorax occurred and was treatedby chest tube in all cases. Radiographic and symptomatic improvement occurred in all patients. Afterthat, bullectomy was performed safely in 2 patients and intrabullar suction with fibrin glue was performedin 1. There were 6 cases with infected bulla that was not improved by the administration of antibiotics. After intracavity drainage, control of infection was achieved, and all but 1 patient were dischargedwithout drain and complications. Intracavity drainage under local anesthesia is a safe and effectivetreatment for giant emphysematous bulla and infected bulla.

The purpose of performing pleural cauterization is developing heat denaturation, and we can inducepleural thickening and also reduce the bullae by shrinking the pleura. It originates in a method of thecauterization whether there will be tissue damage. So a safe and reliable method of cauterization isrequired. Here, we investigated the indications for and effectiveness of cauterization techniques performedat our facility. We perform cauterization while dropping saline solution, so when using a SalientMonopolar Sealer, we can avoid excessive thermo-coagulation and more easily control cauterization.Furthermore, on the basis that only emphysematous pleura will turn white on cauterization, bullae canbe distinguished, which is particularly effective in the case of lesions with unclear borders. In the caseof a large emphysematous bulla, shrinkage of the bulla by cauterization can provide a sufficient surgicalfield, and a smaller lesion can then be stapled.

We address 3 important keys to obtain successful outcomes in surgery for emphysematous giant bullae.It is the 1st step to select patients who might benefit from bullectomy based on functional imaging.The chest computed tomography（ CT） and pulmonary perfusion scintigram provide information regardingwith pulmonary vascular beds which could be recruited by bullectomy. In addition, dynamic-magneticresonance imaging （MRI） during breathing can show a patient with paradoxical inflation of giantbulla during expiration, which means impairment of ventilation of the adjacent normal parenchyma, andis a promising sign for successful outcome of bullectomy. Second, it should be emphasized to perform aproper procedure in bullectomy. If a giant bulla has a wide bottom, it should be recommended to openthe bulla and to plicate it by sutures without injury of vessels on the bottom of the bulla rather thansimple bullectomy with staples. Finally, it is important to keep inflated lung avoiding atelectasis following operation by minimum pressure of suction. We show here sequential bullectomies on a 41-year-oldmale with chronic obstructive pulmonary disease （COPD） GOLD Ⅳ due to bilateral giant bullae andpoor vascular reserve, and address our strategy described above.

A 77-year-old man on hemodialysis was admitted to our hospital due to heart failure. Echocardiographyshowed aortic valve stenosis and regurgitaion, mitral valve stenosis and regurgitaion, and tricuspidvalve regurgitation. Catheter examination revealed severe calcification at aortic valve and mitral valveincluding their annulus. At the operation, the calcifications of the aortic and mitral valvular annulus wasremoved using a Cavitron Ultrasonic Surgical Aspiratior （CUSA）. Reconstructions of the defect of theposterior part of the mitral annulus and of the aortic annulus at the site of the left coronary cusp wereachieved by patch technique using autologous pericardium. Aortic and mitral valve replacement andtricuspid valve annuloplasty were performed. The postoperative course was uneventful. Operativetechnique to remove calcification from valvular annulus using CUSA and reconstruct of the defect of theannulus with autologous pericardium is a very useful technique to prevent left ventricular rupture, perivalvularleakage and any other complications.

A 65-year-old man with left subclavian artery aneurysm, detected by enhanced computed tomography（CT）, was referred to our hospital. The CT revealed intrathoracic left subclavian artery aneurysm（maximum diameter, 5 cm） at the takeoff of the aortic arch. Surgery was indicated considering therisks of rupture and embolism. The aneurysm was exposed through median sternotomy. Cardiopulmonarybypass was established with cannulation of the right axillary artery, left femoral artery, superiorvena cava（ SVC）, and inferior vena cava（ IVC）. Circulatory arrest and isolated cerebral perfusion wereachieved at a core temperature of 23 ℃. Total arch replacement was performed using a 26 mm4-branched Triplex graft, and the left subclavian artery was reconstructed by branch-left axillary arterybypass. The postoperative course was uneventful. He was discharged on the 22nd postoperative day.