胸部外科
Volume 64, Issue 8, 2011
Volumes & issues:
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特集【胸部外科診療に役立つ疾患別最新データ】
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I.心臓血管領域:1.虚血性心疾患
64巻8号(2011);View Description Hide DescriptionCoronary artery bypass grafting (CABG) surgery is the gold standard therapy for the completerevascularization of patients with multivessel coronary artery disease. Since off-pump CABG( OPCAB)began to be performed, to avoid any side effects from cardiopulmonary bypass, OPCAB is now performedin 66% of all isolated CABG in Japan, and this situation is markedly different from the proceduresperformed in North America and Europe. Furthermore, percutaneous coronary intervention( PCI)using drug eluting stents( DES) is now being increasingly performed for the treatment of patients witheither left main trunk, diffuse or multivessel lesions. Under these circumstances, both the surgical treatmentand indications for ischemic heart disease has also changed, and therefore what is asked of surgeonsis how they can provide high quality treatment that maintains surgical quality. The strategy tobe pursued by surgeons in the future is to perform treatment that is less invasive and provides maximumeffects and it is believed that the following issues will become more important. ① Using arterialgrafts for various purposes to maintain high rates graft patency. ② Successfully performing multivesselbypass procedures and achieving good complete revascularization rates. ③ Careful postoperative managementand its complications. -
I.心臓血管領域:2.急性心筋梗塞の機械的合併症
64巻8号(2011);View Description Hide DescriptionTreatment for acute myocardial infarction changed with improvement of coronary intervention. Mostof acute myocardial infarction can be treated by coronary intervention, and number of emergent coronaryartery bypass cases decreased. But, treatment of postinfarction mechanical complication is impossibleby catheter intervention, and emergent surgical treatment is necessary. Major postinfarctionmechanical complications are cardiac rupture, ventricular septal rupture and papillary muscle rupture.Results of surgical treatment for postinfarction mechanical complications are not satisfactory and earlydiagnosis and early surgical treatment can improve treatment outcome. -
I.心臓血管領域:3.大動脈弁膜症
64巻8号(2011);View Description Hide DescriptionAortic valve disease, especially aortic stenosis, is increasing due to the increase in age related aorticvalve degeneration. Although increase in aging population and co-morbidities such as diabetes, renaldysfunction and systemic vascular disease, the result of aortic valve replacement is improving. Operativemortality of isolated aortic valve replacement was 1.9% in Japan. Concomitant procedure suchmitral valve surgery, tricuspid valve surgery, or coronary artery bypass grafting resulted in nearly 2fold increase in mortality. Regarding reoperation, there were 2 to 3 fold increases in mortality in eachcategory. A new technology, trans-catheter aortic valve implantation( TAVI), has been introduced clinically.After going through the learning curve, the results of TAVI are improving. The procedure mayhave a role in most difficult group of patients who had not been considered for surgery due to contraindicationfor open heart surgery. -
I.心臓血管領域:4.僧帽弁膜症
64巻8号(2011);View Description Hide DescriptionI reviewed the literature on surgical cases of the mitral valvular disease and picked out papers whichoffer beneficial data for informed consent on mitral valvular surgery.Japanese registries of thoracic cardiovascular surgery in current ten-years showed that the cases ofmitral valvuloplasty (MVP) have gradually increased and those of mitral valve replacement (MVR)with mechanical valve prostheses have gradually decreased.The current guideline for indication of PTMC, the surgical indication of mitral regurgitation( MR) andthe choice of the valve prosthesis are presented.The freedom from structural valve deterioration after MVR with bioprosthesis and valve related complicationswith mechanical valve prosthesis, derived from major reports, are demonstrated.The freedom from reoperation and recurrence of MR after MVP for posterior, anterior and both leafletsare demonstrated. Recently, the differences between Barlow disease and fibroelastic deficiency inMR have been focused. To assess the prognosis and morbidity after MVP for MR, several papersemphasized that not only the location of the prolapse lesion but the etiologic classification of the degenerativemitral valve disease is also important. -
I.心臓血管領域:5.感染性心内膜炎
64巻8号(2011);View Description Hide DescriptionStreptococcus species has been most common causative micro-organism in infective endocarditis, butthe rate of Staphylococcus species increased lately, particularly the increase of methicilline resistanceStaphylococcus was issue. We advocate early surgical intervention in cases with infective endocarditisinvolved congestive heart failure, resistance of antibiotics and/or embolism. In mitral valve endocarditis,many surgeon have tried valve plasty, the result has been improved. In case with prosthetic valve endocarditis,particularly involved annular abscess, preoperative worse condition, the necessity of complicatedsurgical technique, and the recurrence of infection resulted in poor outcomes. We strongly advocateearlier surgical intervention and wish easy access and availability of homograft. -
I.心臓血管領域:6.心房細動
64巻8号(2011);View Description Hide DescriptionAtrial fibrillation was frequent and troublesome arrhythmia, which caused cerebral embolism andheart failure. Recent advances of therapeutic research for atrial fibrillation make the radical therapypossible by catheter ablation and surgical procedures. -
I.心臓血管領域:7.真性胸部大動脈瘤
64巻8号(2011);View Description Hide DescriptionRecently, managing thoracic aortic aneurysms( TAA) identified incidentally by increased use of computedtomography especially in the elderly. Although many TAA are degenerative in etiology, othercommon causes of thoracic aortic pathology include connective tissue diseases.In our country, current knowledge of prevalence, incidence and survival in TAA is based on a fewstudies from a dated era of treatment and diagnostic procedures. Surgical repair (open surgery andendovascular surgery) of TAA may carry low morbidity and mortality, depending on experience of thesurgeon and operative technique used. In fact, surgical strategies for the treatment of TAA have beendramatically changed in this decade, resulting in better outcomes. Nevertheless, considering mortalityand morbidity, TAA is still serious problem for patient life. Therefore, methods to assess risk of ruptureto help determine the best time for surgical repair and the knowledge of accurately TAA data are veryimportant.The major concern in the surgical repair of TAA is the risk of cerebral infarction, paraplegia and hospitaldeath. We classified TAA into 5 categories;annulo aortic ectasia (AAE), ascending aortic aneurysm,aortic arch aneurysm, descending thoracic aneurysm and thoracoabdominal aneurysm. Here wedescribe the epidemiology, surgical outcomes, long-term outcomes and complication rate focused cerebralinfarction and paraplegia in subjects with TAA for each groups. -
I.心臓血管領域:8.大動脈解離
64巻8号(2011);View Description Hide DescriptionAcute aortic dissection suddenly occurrs and results in a variety of catastrophic sequelae includingcardiac tamponade, rupture, and organ malperfusion. In acute stage( < 2 weeks), according to the classificationson the region of aortic dissection, the condition of the false channel and the onset, appropriatemedical, surgical, or endovascular treatments including endovascular aneurysm repair followed by therapid and accurate diagnosis of aortic dissection using computed tomography and ultrasound should beperformed without delay. In the chronic stage (> 2 weeks), the behavior of the chronic dissection orresidual distal dissection after the initial treatment should be followed-up carefully with best medicaltreatment at the regular intervals. If necessary, appropriate surgical and endovascular treatment shouldbe carried out in the proper timing before rupture. -
I.心臓血管領域:9.心臓腫瘍・収縮性心膜炎・肺動脈血栓塞栓症
64巻8号(2011);View Description Hide DescriptionCardiac tumors are rare, and 3-quarters of these tumors are benign and nearly half of the benigntumors are myxomas. Metastases to the heart are more common than primary cardiac tumors. Cardiactumors present obstructive, constitutional and embolic signs and symptoms. Echocardiograms, chest computed tomography( CT) and magnetic resonance imaging( MRI) scan are very useful for diagnosis.Surgery is indicated in patients with benign tumor, and chemo/radio-therapy in patients with malignanttumors. Prognosis after surgery is good, instead poor prognosis for patients with malignancy.Constrictive pericarditis is mainly result of idiopathic, previous cardiac surgery and radiation in recentyears. Diagnosis is made by echo cardiography and cardiac catheterization along with clinical presentation.Thickened pericardium is directly diagnosed by currently advanced transesophageal echocardiography,CT and MRI although normal thickness of the pericardium with constrictive pericarditis isobserved in some patients. Pericardiectomy is the only treatment for permanent constriction.The incidence of pulmonary thromboembolism is currently increasing in Japan. Guidelines for thediagnosis, treatment and prevention of pulmonary thromboembolism and deep vein thrombosis (JCS2009) is helpful for diagnosis and treatment decision. Anticoagulant is initial treatment for acute pulmonarythromboembolism, and intravenous thrombolysis is performed in hemodynamically unstable cases.Chronic thromboembolic pulmonary hypertention is treated by pulmonary endarterectomy whereasanticoagulant and vasodilator are used for peripheral type and mild cases. -
I.心臓血管領域:10.心筋症・心筋炎など
64巻8号(2011);View Description Hide DescriptionMedical treatment is the 1st choice for cardiomyopathy and myocarditis. Adequate medical treatmentis not sometimes insufficient, and advanced heart failure condition may be brought about in fulminantmyocarditis, dilated cardiomyopathy( DCM) and dilated phase of hypertrophic cardiomyopathy( dHCM).Although left ventricular restoration operation is conducted in selected cases of these cardiomyopathies,hospital mortality is high partly due to lack of uniform indication of this type of surgery. Mitral valveplasty including (restrictive) annuloplasty and submitral apparatus procedures or mitral valve replacementwith chordal preservation is performed in mitral valve regurgitation accompanying mitral tethering.In an end-stage heart failure, implantation of ventricular assist device( VAD) or heart transplantationmay be indicated. Two kinds of small Japan-made implantable devices have been approved forclinical use. EVAHEART is a 2nd-generation centrifugal VAD which is equipped with unique cool-sealsystem. DuraHeart is a 3rd-generation centrifugal VAD which has magnetical levitation system. TheRevised Organ Transplantation Law has become effective July 2010. The number of heart transplantationis increasing since then. Ninety-six heart transplantation were performed as of the end of February2011, and 10-year survival rate is 95%, which is far superior to international data. -
I.心臓血管領域:11.短絡のない非チアノーゼ性心疾患
64巻8号(2011);View Description Hide DescriptionThe incidence of moderate and severe forms of congenital heart disease is about 6/1000 live births.Management and results of non-cyanotic and no shunt lesion were described. -
I.心臓血管領域:12.短絡のある非チアノーゼ性心疾患
64巻8号(2011);View Description Hide DescriptionMinimally invasive cardiac surgery has been performed for patients with patent ductus arteriosus(PDA), atrial septal defect (ASD), and ventricular septal defect (VSD). Video-assisted thoracoscopicinterruption of PDA (VAT-SPDA) is effective for infants and neonates, especially for low birth weightbabies. On the other hand, catheter intervention using PDA and ASD occluder devices have beenwidely used in our country. However, serious complications were reported in some papers. Recently,the device occlude has been applied to VSD. In percutaneous approach, there have been serious complicationssuch as aortic regurgitation and complete atrioventricular block. The transatrial and perventricularapproach are now advocated to avoid these complications. These approaches are called “hybridapproach”, which is achieved with collaboration between catherter interventionists and cardiac surgeons.In the future, the hybrid approach including stent graft insertion and transaortic valve implantationwould be important alternative procedure in both adult and pediatric cardiovascular surgery. -
I.心臓血管領域:13.短絡のあるチアノーゼ性心疾患(1)
64巻8号(2011);View Description Hide DescriptionThis section deals with subgroups of cyanotic complex congenital heart diseases, most present early inlife during neonatal period or early infancy. And some present with ductal dependency for survival.Here included are the complete transposition of the great arteries( TGA)[or Taussig-Bing anomaly]with/without aortic arch obstruction, total anomalous pulmonary venous connection( TAPVC), pure pulmonaryatresia/stenosis (PPA/PPS) [pulmonary atresia with intact ventricular septum (PA/IVS) orcritical pulmonary stenosis], hypoplastic left heart syndrome(HLHS) and its variants. In d-TGA casesexcept those with left ventricular outflow obstruction, primary Jatene procedure with/without concomitantrepair of the aortic arch obstruction is the procedure of choice with good surgical and long-termresults although acceptable rate of re-intervention is mandatory. In TAPVC, primary repair usuallygoes with good long-term result, although minority of the patients eventually develops for midable complication,postoperative pulmonary venous obstruction. Sutureless pericardial repair has been developedfor coping with and later for prevention of this complication with promising mid-term results. Its introductionin primary repair especially in complex cases appears around the corner. HLHS and its variantshas been the most challenging group of patients requiring staged approach starting with Norwood procedureor bilateral pulmonary artery banding. Right ventricle-to-pulmonary artery conduit, introducedas a Japanese innovation, has contributed marked improvement of surgical results although furtherrefinements surely are necessary. Patients with PPA/PPS have a wide range of clinical pictures withintrinsic problems of right ventricle, tricuspid valve and associated coronary artery abnormalities. Adequateuse of single ventricle physiology in many cases offers fair surgical results. -
I.心臓血管領域:14.短絡のあるチアノーゼ性心疾患(2)
64巻8号(2011);View Description Hide DescriptionTetralogy of Fallot is the most common cyanotic heart disease. Its operative mortality and long-termresult are quite good in these days. At the late phase after the correction, pulmonary valve regurgitationassociated with right side heart failure, aortic valve regurgitation, arrhythmia and sudden deathbecome major adverse outcomes. Double-outlet right ventricle is a cyanotic heart disease with a widespectrum of morphology and is divided according to the site of ventricular septal defect;subaortic, subpulmonary,doubly committed and remote type. Its operative methods are completely dependent on itsmorphology, and vary such as intracardiac tunnel repair, Rastelli type repair, arterial switch procedureand Fontan type repair. Left ventricular outflow tract obstruction is one of the most important problemsafter the correction. Recent operative strategies for the treatment of tricuspid atresia and singleventricle are quite similar and its final goal is the completion of right heart bypass operation using totalcavo-pulmonary connection with staging strategy. Pleural effusion, ascites, protein loosing enteropathyand supraventricular arrhythmia are major adverse outcomes after Fontan type repair, while extracardiactotal cavopulmonary connection is expected to reduce the incidence of supraventricular arrhythmia. -
II.呼吸器領域:1.原発性肺癌
64巻8号(2011);View Description Hide DescriptionWith the recent increase of lung cancer patients, small sized lung cancers are frequently found withthe widely using of computed tomography(CT). In November 2010, National Cancer Instituteannounced that the routine medical examination with using low dose helical CT reduced the lung cancerdeath rate by 20%, compared with plain chest X-ray. For the small sized lung cancers, several clinicalstudies for limited surgery and stereotactic radiation therapy are on going now. On the other hand, based on the development of radiation and chemotherapy, treatment results of locally advanced lungcancer are improving. Several studies reported that postoperative adjuvant chemotherapy improved theprognosis by 10-15%. Neoadjuvant chemotherapy or chemoradiotherapy have also been reported toimprove the postoperative survival compared with the treatment by surgery alone. Postoperative mortalityrate has been decreased to 0.9% according to the recent report from Japanese Thoracic SurgicalSociety.Like these, surgical treatment for lung cancer has been developed certainly with advancing radiologicaldiagnosis, radiation therapy, chemotherapy, and perioperative management. -
II.呼吸器領域:2.転移性肺腫瘍
64巻8号(2011);View Description Hide DescriptionThe lung metastasis remains the major cause of cancer related mortality in patients with solid malignanttumor. In general, the treatment of the lung metastasis is the systemic chemotherapy or the targetedtherapy suitable for the primary lesion.However, the surgical resection of the lung metastases could enhance the survival for the chemotherapy-resistant lung metastasis only if, certain criteria are met.Recent advance of the thoracoscopic technology led to increase the number of the lung metastasectomy.Low-invasive video assisted thoracoscopic resection is beneficial for the lung metastasis as long asthe primary lesion confined to the lung before systemic disease. This treatment has low complicationrates and has a beneficial influence on the course of the disease.We reviewed our experience in evaluating the surgical outcomes in cancer patients who have undergonea lung metastasectomy by thoracoscopic resection. -
II.呼吸器領域:3.悪性胸膜中皮腫
64巻8号(2011);View Description Hide DescriptionMalignant pleural mesothelioma (MPM) is a rare thoracic malignancy associated with very poorprognosis.Extrapleural pneumonectomy (EPP), a very invasive surgery where en bloc resection of ipsilateralpleura, lung, and a part of diaphragm and pericardium is required, is performed with curative intent.However, EPP remains to be cytoreductive rather than radical surgery for MPM, because its goal ismacroscopic complete resection. In this context, preoperative chemotherapy with cisplatin and pemetrexed,followed by EPP and postoperative hemithoracic radiation is currently considered as “standardtherapy”for resectable MPM.Results of recent major clinical trials on trimodality treatment (TMT) for MPM were not encouraging;TMT was completed in approximately 50% of enrolled patients, and overall survival ranged 14 to18.4 months. However, in Toronto trial, median survival reached to 59 months in patients who had nomediastinal node involvement and completed the entire TMT. This fact clearly illustrates that patientselection plays a key roll in MPM treatment.An all-Japan clinical study on TMT feasibility is currently underway. -
II.呼吸器領域:4.胸腺腫と胸腺癌
64巻8号(2011);View Description Hide DescriptionThymoma and thymic carcinoma are neoplasms originating from the epithelial cells of the thymus.Although these tumors should be treated according to the pathological diagnosis and the stage, theyhave distinct characteristics in the clinical behaviors, and therefore, should be treated separately. Thestandard treatment strategy has not been established because of the rarity of these tumors, but therecent accumulation of experiences provided some insights into therapeutic method for these tumors.In thymoma, Masaoka staging and completeness of surgical resection are important factors to determinethe therapeutic method. Stage Ⅰ and Ⅱ thymomas are often good candidates for less invasiveapproach by endoscopic surgery. Highly invasive stage Ⅲ thymoma, especially with involvement of thegreat vessel, is supposed to be treated with preoperative chemotherapy. Postoperative adjuvant therapyafter complete resection has not been shown to have significant effect. Stage ⅣA thymoma patientswith pleural dissemination sometimes achieve long term survival after resection, and even subtotalresection has some value.In thymic carcinomas, patients often appear with advanced stage, and multimodality treatment ismore frequently recommended than thymomas. Histological grade of aggressiveness is also an importantfactor for prognosis.Further study is still required for establishment of the universal approach to these tumors includingTNM classification. -
II.呼吸器領域:5.胸壁・肋骨の腫瘍
64巻8号(2011);View Description Hide DescriptionPrimary chest wall tumors consist of 5% of all thoracic tumors and 0.04% of all primary tumors.Almost half of primary chest wall tumors are benign. Over half are metastases from distant malignanciesor direct invasions from adjacent malignancies such as breast cancer, lung cancer, mesotheliomaand mediastinal tumor. Chest wall mass can form from trauma and infection. So it is important to takea medical history including past trauma and infection. Past history of cancer and radiation is also important.While diagnostic imaging such as computed tomography (CT) and magnetic resonance imaging(MRI) is valuable in determining boundary of tumor and detecting invasion to the nerves and vessels,biopsy should be performed to confirm diagnosis. Then the strategy for each patient with chest walltumor should be planed according to the results of preoperative examinations. For high grade malignancy,such as osteosarcoma and Ewing sarcoma, multidisciplinary treatment including chemotherapyshould be considered. For an unresectable case or patient with inadequate margin at previous chestwall resection, radiation should be considered. Radio-sensitive neoplasm such as desmoid tumorresponds well to radiation. Wide resection of malignant chest wall tumor is the treatment of choice.Although a 2-cm surgical margin may be adequate for chest wall metastasis, benign chest wall tumorand chondrosarcoma, malignant chest wall tumor undergo wide resection to include a 4-cm margin.Selection of chest wall reconstruction for each patient is also important to prevent postoperative complication. -
II.呼吸器領域:6.中枢気道の腫瘍
64巻8号(2011);View Description Hide DescriptionTumors of the tracheobronchus consist of tracheobronchial gland tumor, squamous cell carcinoma, andother tumors. Tracheobronchial gland tumors, such as adenoid cystic carcinoma or mucoepidermoidcarcinoma, are rare tumors, and resemble salivary gland tumors pathologically. Surgical complete resectionshould be considered if possible. Radiotherapy alone results in less survival compared to completeresection. Radiotherapy or palliative bronchoscopic recanalization is a choice of therapy when unresectable.Over all survival rate after operation has been reported to be 66〜79% at 5-year and 51〜57% at10-year. Mortality of the surgery is less than 5% in Japan. Adjuvant radiotherapy is often adoptedwhen surgical margin is pathologically positive, since adenoid cystic carcinoma is thought to be radiosensitivetumor. -
II.呼吸器領域:7.肺化膿症と肺膿瘍
64巻8号(2011);View Description Hide DescriptionPulmonary suppuration is defined as necrosis of the pulmonary parenchyma caused by microbial infection.Pulmonary suppuration may be primary or secondary based upon the presence or absence of commonassociated conditions. Abscesses in patients prone to aspiration are usually considered primary;the term secondary lung abscess typically indicates an associated bronchogenic neoplasm or systemicdisease that compromises immune defenses, such as the acquired immunodeficiency syndrome( AIDS)or organ transplantation. In 70 to 90% of cases it is caused by anaerobic bacteria or by co-infection ofanaerobic and aerobic bacterium. Thus, pulmonary suppuration is treated with antibiotics, which leadsto recovery from the disease in at least 80% of cases. For patients who do not respond to antibioticadministration or those with secondary pulmonary suppuration( particularly following primary lung cancer),surgical resection or percutaneous transthoracic drainage (PTD) are the procedures of choice.Although surgery leads to good recovery rates, the risk of developing post-operative complications andmortality are also elevated. Unlike surgical resection, performing PTD provokes little loss of pulmonaryfunction and therefore, it should be recommended to high risk patients who cannot undergo lung resection. -
II.呼吸器領域:8.非結核性抗酸菌症
64巻8号(2011);View Description Hide DescriptionMycobacterium avium complex (MAC) is the most common nontuberculous mycobacterial pathogenin Japan. There are 2 major types of clinical manifestations of MAC disease, including fibrocavitary diseaseand nodular bronchiectatic disease. Primary treatment of MAC disease is medical treatment.Standard multidrug regimens employ clarithromycin, rifampicin, and ethambutol. Aminoglycoside(streptomycin or kanamycin) is added if necessary. Patients whose disease is predominantly localizedto 1 lung and who can tolerate resectional surgery may be considered for surgery under the followingcircumstances;poor response to drug therapy, the development of macrolide-resistant MAC disease, orthe presence of hemoptysis. Surgery for MAC lung disease can achieve favorable treatment outcome.However, surgery is associated with significant morbidity, especially when pneumonectomy is performed.When surgical intervention is considered necessary for MAC patients, pulmonary resectionshould be performed before MAC lung disease has progressed too extensively to avoid pneumonectomy. -
II.呼吸器領域:9.肺真菌症
64巻8号(2011);View Description Hide DescriptionSurgical resection of pulmonary aspergilloma contributes not only to controlling severe symptoms butalso to the cure for aspergillosis. Early morbidity and mortality that recently reported are acceptable.The operative mode must be selected appropriately according to the status of disease. The prognosisand the postoperative course of accidental surgical resection of pulmonary cryptococcosis are excellent. -
II.呼吸器領域:10.降下性壊死性縦隔炎
64巻8号(2011);View Description Hide DescriptionDescending necrotizing mediastinitis (DNM) is a life-threatening condition, in which infection arisingfrom deep neck tissue spreads downwards into the mediastinum. Contrast-enhanced cervico-thoraciccomputed tomography(CT) scan is vital for appreciate of the extent and location of mediastinalinvolvement. Treatment of DNM begins with intravenous administration of a broad-spectrum antibioticcovering both aerobes and anaerobes. Immediate transcervical drainage and debridement with or withouttransthoracic mediastinal drainage should be considered. Transthoracic mediastinal drainage has tobe performed when the mediastinal infection has spread below the carina and/or the Th4 vertebra.Moreover, it is important to determine whether additional drainage is required by evaluation using regularCT imaging. The overall reported mortality rate since 1960 has been 31%, but from 1999 to 2008 ithas been 15.5%. -
III.食道領域:1.食道損傷の診断と治療―特発性食道破裂を中心に
64巻8号(2011);View Description Hide DescriptionSpontaneous esophageal rupture is a comparatively rare disease, and thought to be a severe emergencydisease clinically. Most patients of spontaneous esophageal rupture complained of chest pain aftervomiting, which required an appropriate diagnosis. Emergency operation for the extra-mediastinal rupturetype and intra-mediastinal rupture type, also conservative treatment for the intra-mediastinal rupturetype achieved satisfactory results. The procedure consisted of closure of the perforation site withleft thoracotomy and gastric fundic patch via the transhiatal approach. To prevent post-operative empyemaand mediastinal abscess formation, insertion of a conventional thoracic drainage tube and anotherfixed drainage tube from the posterior diaphragm to the lateral border of the vertebral column along thethoracic descending aorta seemed effective. The patients with spontaneous esophageal rupture underwentcontinuous irrigation and suction via these drainage tubes after the operation. -
III.食道領域:2.逆流性食道炎(食道裂孔ヘルニア)
64巻8号(2011);View Description Hide DescriptionRecently, the guidelines for the treatment of gastroesophageal reflux disease( GERD) by the JapaneseSociety of Gastroenterology. There are many statements including recommended grade( from A to D)and evidence level( from I to VI) for the epidemiology, pathogenesis, diagnosis, medical treatments, surgicaltreatment of GERD, reflux esophagitis after gastrectomy, and non-typical symptoms of GERD. Inthis manuscript, we showed the latest date and current status of GERD in Japan used this guidelines.In summary, the prevalence of GERD has been increasing since the end of 1990s, the 1st choice ofmedical treatment is proton pump inhibitors, endoscopic treatments for GERD are not available in Japan,laparoscopic Toupet fundoplication is superior to laparoscopic Nissen fundoplication as postoperativedysphagia with similar reflux control, and complications of surgical treatment are pneumothorax, splenicinjury, aortic injury, gastric ulcer, sever dysphagia, gastric perforation etc., but complication rate is low. -
III.食道領域:3.食道運動機能障害―アカラシアを中心に
64巻8号(2011);View Description Hide DescriptionEsophageal motility disorders are classified primary and secondary, and primary esophageal motility disorders are classified esophageal achalasia and other diseases by manometry. An esophageal emptyingdisorder associated with insufficient relaxation of the lower esophageal sphincter( LES) and eliminationof peristaltic waves on the esophageal body is the major abnormality of achalasia. Esophagogram,endoscopy, and manometry are used for diagnosis. As pharmacological therapy, administration of a calciumchannel blocker or nitrate is useful. The pharmacological therapy is not recommended as longterm basic therapy but as a temporary treatment. At 1st, the balloon dilation method is chosen in treatmentof achalasia. Surgical treatment is indicated in the following cases:① Patients uneffected by balloondilation, ② Flask type with grade II to III dilation, and sigmoid type, ③ the gradual progression tothe pathophysiological stage, ④ young patients, ⑤ complicated with esophageal cancer. LaparoscopicHeller-Dor procedure is the most popular surgical procedure, recently. It is somewhat difficult to performsurgical treatment for this functional disease. We should select the most suitable individualizedtreatment with efficient comprehension of the pathophysiological situation. -
III.食道領域:4.食道癌
64巻8号(2011);View Description Hide DescriptionEsophageal cancer is the 6th most common cancer in Japan. For the early cancer without lymphnode metastasis, endoscopic resection is commonly performed. Esophagectomy with 3-field lymphadenectomyis the standard therapy for resectable esophageal cancer (stage Ⅰ〜Ⅳ). Chemoradiotherapy(CRT) is the standard therapy for unresectable esophageal cancer and could also be considered as anoption for resectable esophageal cancer. The complications of endoscopic resection are stenosis, perforation,pneumomediastinum, and so on. Major surgical complication are anastomotic leakage, recurrentnerve paralysis, heart failure, respiratory insufficiency. The rates of complications increase after salvageoperation, therefore, hospital mortality rate is 7〜15%. The serious complications of chemoradiotherapyare late pericardial effusion and pleural effusion.
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