胸部外科
Volume 64, Issue 9, 2011
Volumes & issues:
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胸部外科の指針
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Norwood 型手術を要した大動脈弓離断複合に対する治療戦略
64巻9号(2011);View Description Hide DescriptionBackground:Interrupted aortic arch (IAA) is associated with a multitude of lesions ranging fromisolated ventricular septal defect to hypoplastic left ventricle or severe subaortic stenosis (SAS). Leftventricular outflow obstruction such as SAS continues to be an important factor for deciding the surgicalprocedure between univentricular and biventricular repairs.Methods:A retrospective study was conducted in 8 consecutive infants aged 14 to 117 days andoperated on between 2004 and 2009. Seven patients had undergone bilateral pulmonary artery bandingfor pulmonary high flow regulation. All patients underwent Norwood-type operation(4 with systemicto pulmonary artery shunt, 3 with right ventricle to pulmonary artery shunt, and 1 with bidirectionalGlenn shunt).Results:One patient died 2 months after surgery due to respiratory failure. The others were dischargedin a good condition. One patient underwent Rastelli-type operation and biventricular circulation was achieved. The other 6 patients were all Fontan candidates.Conclusion:Satisfactory initial palliation can be achieved by Norwood-type operation for IAA withsevere SAS or hypoplastic left ventricular-aortic complex
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今月の臨床
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胸腔鏡下肺区域切除術後に生じる不良肺例の検討
64巻9号(2011);View Description Hide DescriptionPulmonary segmentectomy by video-assisted thoracic surgery( VATS) is used for minimally invasivesurgery for removal of small lung neoplasms, and stump consolidation is one of the potential postoperativecomplications. The objective of the present study is to clarify the incidence of stump consolidationand its predictive factors by assessing patients who underwent VATS segmentectomy in our department.Stump consolidation was defined as atelectatic lesions along the surgical stump with >10 mmthickness in horizontal sectional view by computed tomography, at least 3 months after surgery.Between February 2007 and September 2010, 70 patients (38 men and 32 women) with primary lungcancer (43 patients) and metastatic pulmonary tumor (27 patients) underwent VATS segmentectomy.Stump consolidations were seen in 7 patients. Univariate analysis showed the significant ditlerence forthe period of performed operation. Left-sided operation, especially segmentectomy of left S1+2, wasanother predictive factor, though not significant. Stump consolidation after VATS segmentectomy canbe deueloped by conbined workspace for stapling and misidentification of intersegmental plane. Whendivision of the intersegmental plane is difficult, open thoracotomy should be undertaken to prevent suchcompliance.
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臨床と研究
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結紮用クリップを用いた両側肺動脈絞扼術の実験的検討
64巻9号(2011);View Description Hide DescriptionBilateral pulmonary artery banding (PAB) using constrictive tapes encircled around both pulmonaryarteries entails frequent post-debanding residual pulmonary artery stenosis. We devised a new techniqueof bilateral PAB using half-closed surgical clips. Surgical clips, applied half-closed around both pulmonaryarteries, transform the cross sections of the pulmonary arteries into diamond-shapes, and reducetheir cross sectional areas without significantly reducing their circumferences. Animal experiment usingbeagles indicated that bilateral PAB using half-closed surgical clips is technically feasible and reproducible,causes less pulmonary arterial intimal proliferation and entails lower risk of residual pulmonaryartery stenosis than bilateral PAB using constrictive tapes. -
アクティブメガネシャッター方式を用いた三次元表示・手術術前シミュレーション
64巻9号(2011);View Description Hide DescriptionWe have reported preoperative 3-dimensional (3D) simulation of thoracoscopic lung surgery usingself-made software and internet shareware of 3D-modeler. Using“ active shutter glasses”, we have triedthe“ 3D display simulation” of lung surgery. 3D display was more effective to grasp clear 3D interrelationbetween the bronchii and pulmonary vascular system than those in images of currently in use withthe same information volume.
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今月の話題
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心肺停止に陥ったが救命しえた急性肺血栓塞栓症
64巻9号(2011);View Description Hide DescriptionAcute massive pulmonary thromboembolism (APE) is still associated with a high mortality rate.Furthermore, significantly higher mortality rates are observed in patients who underwent cardiopulmonaryresuscitation (CPR) because of severe brain damage or multiple organ failure. We present successfullytreated 4 patients who were transferred from outside hospitals under continuous CPR. Threeof 4 patients required percutaneous cardiopulmonary support( PCPS). Preoperatively, all 4 patients hadno brain damage despite of CPR for a maximum of 40 minutes. Open pulmonary thrombectomy wassuccessfully performed under on pump beating cardiopulmonary support.All patients dramatically improved and were discharged without any complication. When hemodynamicinstability or cardiac arrest occurs in patients with APE, rapid CPR, rapid diagnosis with echocardiography,and quick PCPS establishment are keys in our management strategy.
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術前・術後管理
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手術適応境界域の重度呼吸機能障害を伴った大動脈弁狭窄症患者に対する術前呼吸リハビリテーション
64巻9号(2011);View Description Hide DescriptionWe describe 2 cases of aortic valve stenosis with severe pulmonary dysfunction. Preoperative respiratoryrehabilitation programmed by the rehabilitation doctors was cautiously undertaken to improve theirexercise tolerance and respiratory reserve. These 2 patients underwent aortic valve replacement eventually.Postoperative course in each patient was uneventful without respiratory complication. Preoperativerespiratory rehabilitation can be performed in the high risk patient with severe pulmonary dysfunctionas long as careful risk management is guaranteed.
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手術の工夫
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DeBakey 分類IIIa 型慢性遠位弓部大動脈瘤に対してelephant trunk で血栓閉鎖を得た弓部大動脈全置換術
64巻9号(2011);View Description Hide DescriptionA 74-year-old man was diagnosed with Stanford type B early thrombosed aortic dissection. Computedtomography( CT) 2 years later revealed that an aneurysm of the distal arch had enlarged from a maximaldiameter of 47 mm to 62 mm and involved the descending aorta. Total arch replacement using aquadrifurcated arch graft proceeded through a median sternotomy under deep hypothermic cardiopulmonarybypass (20 ℃) and selective brain perfusion. The long elephant trunk of another prosthesis was inserted into the descending aorta and a distal anastomosis was constructed immediately after theleft common carotid artery. The post-operative course was uneventful and CT at that time revealedcomplete thrombo-exclusion of the aneurysm surrounding the long elephant trunk. This method wasvery useful for reducing the duration of circulatory arrest and bleeding, as well as the risk of postoperativecomplications.
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臨床経験
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左冠状動脈主幹部解離に対しステント留置術を先行させたStanford A 型急性大動脈解離
64巻9号(2011);View Description Hide DescriptionAn 80-year-old woman was transferred to our hospital with sudden onset of chest pain. Electorocardiogram(ECG) showed ST-segment elevation of V1-V3 and aVL leads suggestive of acute coronary syndrome.On emergent coronary angiography, left main trunk( LMT) was externally compressed only atdiastolic phase, showing acute type A aortic dissection involving the left coronary artery. A bare metalstent was promptly implanted to LMT to restore coronary blood flow because of her hemodynamicinstability. Soon after this procedure, ischemic changes disappeared on ECG and she was transferred tothe operating room in stable hemodynamic condition without chest discomfort. Emergent graft replacementof ascending aorta and proximal portion of transverse arch was successfully performed. As thebare metal stent had been properly implanted at the LMT and weaning from cardiopulmonary bypasswas uneventful regardless of decreased left ventricular wall motion of anteroseptal area, coronary arterybypass grafting was not performed. A “bridge to surgery” use of coronary stenting was very effectiveas a life saving procedure for the patients with acute aortic dissection involving the left coronary artery. -
両大血管右室起始,肺動脈閉鎖症に対する再Blalock-Taussig シャント術
64巻9号(2011);View Description Hide DescriptionA 36-year-old man was admitted to our hospital due to dyspnea and pneumonia. He had undergoneleft classical Blalock-Taussig shunt at 5 years old and right modified Blalock-Taussig shunt at 16 yearsold, because he was judged as no indication for any radical operation. Since the last surgery, he hadstopped visiting hospital. Computed tomography showed pneumonia and pulmonary embolism in the leftlower lung and occlusion of the right modified Blalock-Taussig shunt. After pneumonia was improvedby antibiotic treatment, he underwent reoperation of the right modified Blalock-Taussig shunt using 8mm knitted Dacron graft. Postoperative course was uneventful and dyspnea and cyanosys wereimproved. We successfully treated a complicated case of an adult congenital heart disease by reoperationof the right modified Blalock-Taussig shunt. -
横隔膜転移をきたした子宮体癌
64巻9号(2011);View Description Hide DescriptionWe report a case of metastatic diaphragm tumor from uterine corpus cancer. A 72-year-old femalehad a tumor on right diaphragm 4-years after operation for uterine corpus cancer. After chemotherapy,tumor resection was performed by right lung basal segmentectomy, partial liver resection, and partialdiaphragm resection. The pathological examination revealed adenocarcinoma, compatible with uterinecorpus cancer, metastasizing in diaphragm and involving lung and liver. After the operation, a localrecurrence occurred at parasternal lymph node, which is considered to be present on the efferent routeof lymph flow from diaphragm. -
成人Bochdalek 孔ヘルニアに合併した自然気胸
64巻9号(2011);View Description Hide DescriptionA 71-year-old man, who had been given a diagnosis of Bochdalek hernia in infancy, was referred toour hospital for dyspnea. The chest X-ray and computed tomography (CT) showed left pneumothoraxwith bullas and intestines in his left thoracic cavity. He was admitted to our hospital and a chest tubewas inserted into the left pleural cavity. The left lung expanded immediately and air leakage wasstopped. He became asymptomatic and he was discharged from the hospital on the 8th day. MostBochdalek hernias are observed in infancy, and adult cases combined with pneumothorax and bullas arevery rare.
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症例
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心房中隔瘤を合併した僧帽弁閉鎖不全症の1 例
64巻9号(2011);View Description Hide DescriptionA 64-year-old female was admitted to our hospital because of severe dyspnea. Echocardiographyrevealed mitral valve regurgitation and atrial septal aneurysm( ASA).After instituting medical treatment for congestive heart failure, euvolemic status was achieved, andthe patient underwent;① prosthetic patch repair for ASA;② mitral valvuloplasty with partial quadrangularresection of the posterior mitral leaflet;and ③ mitral annuloplasty using Physio ring. Pathologicalexamination revealed myxomatous degeneration of the mitral valve, but the resected atrial sep tum was without any abnormality.ASA can lead to cerebral or pulmonary embolism even in the absence of an atrial septal defect. However,ASA without atrial septal defect is typically asymptomatic and rarely requires surgical correction.By contrast, ASA with concomitant mitral valve prolapse is associated with a high risk of cerebral orpulmonary embolism.Aspirin therapy is indicated for the prevention of thromboembolism in patients with ASA who do notundergo surgical management, and these patients also require careful observation. -
孤立性三尖弁位感染性心内膜炎の1 例
64巻9号(2011);View Description Hide DescriptionWe report surgically treated case of tricuspid valve endocarditis in a non-drug addict. A 74-year-oldman with no history of cardiac disease was admitted to our hospital for persistent pyrexia. The bloodculture was negative. Echocardiography showed vegetations attached to the tricuspid valve with mildtricuspid regurgitation. Intravenous antibiotics therapy was unable to control the infection. So we performedtricuspid valve repair and annuloplasty using an artificial ring. The postoperative course wasuneventful. After prophylactic antibiotic administration for 15 weeks, he was afebrile for 1 week withoutany medication. Thereafter he was discharged and has been free from any complication for over 16months -
骨転移と考えられた肺性肥大性骨関節症を伴う原発性肺癌の1 例
64巻9号(2011);View Description Hide DescriptionA 64-year-old man visited our hospital, due to right shoulder pain and fever. Chest X-ray revealed awell-defined tumor in the upper field of the left lung, and the histological diagnosis was adenocarcinoma.Bone scintigraphy demonstrated abnormal accumulation localized in the right shoulder joints. Althoughbone metastasis was highly suspected, pulmonary resection was performed to remove infected pulmonarytumor. A week after pulmonary resection, his shoulder pain dramatically improved, and abnormalaccumulation in bone scan decreased definitely 1 month later. In conclusions, this is an atypical case ofhypertrophic osteoarthropathy accompanying lung cancer. -
肺癌との鑑別が困難であった肺放線菌症の1 例
64巻9号(2011);View Description Hide DescriptionWe herein report a case of pulmonary actinomycosis that was difficult to differentiate from lung cancer.The patient was a 53-year-old man who visited our hospital with a chief complaint of bloody sputum.Computed tomography( CT) showed a tumor in the anterior basal segment( S8) of the left lowerlobe that contained a low density area, and because elevated C-reactive protein (CRP) was alsoobserved, the patient was diagnosed with a lung abscess. As no improvements were seen after 4months of antibiotic administration, and accumulation was observed at the same site on positron emissiontomography( PET), the patient was diagnosed with lung cancer and underwent surgery. Followingsegmental resection, the patient was found to have pulmonary actinomycosis. It is necessary to considerpulmonary actinomycosis in patients with lung tumors.
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連載 論文査読者のつぶやき(第1回:新連載)
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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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