Volume 64,
Issue 12,
2011
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胸部外科の指針
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Source:
胸部外科 64巻12号, 1043-1049 (2011);
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We evaluated the effect of preoperative intraaortic balloon pumping (IABP) support in high riskpatients undergoing off-pump coronary artery bypass grafting( OPCAB).Between November 1999 and December 2010, 65 high-risk patients underwent OPCAB with the supportof IABP inserted preoperatively. High risks were considered as( 1) left main coronary artery stemstenosis ≧ 75%, (2) unstable angina requiring intravenous nitrates and heparin, (3) preoperative leftventricular ejection fraction ≦ 30%,( 4) bilateral carotid artery stenosis ≧ 75%.There were no hospital deaths or cerebrovascular complications. During operations, hemodynamicswas stable with the support of low dose catecholamines, and no patient needed conversion to on-pumpcoronary artery bypass grafting. All patients were able to be weaned from IABP within 3 days( mean5.7 hours) after the operation and were extubated within 4 days( mean 11.5 hours) after the operation.One patient had a peripheral embolism which might be related to insertion of IABP( 1.5%).Preoperative IABP in high-risk patients undergoing OPCAB was considered to be useful and safe.
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今月の臨床
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Source:
胸部外科 64巻12号, 1052-1055 (2011);
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We report a case in which the double-patch technique was used to repair residual shunt after infarctexclusion technique for post-infarction ventricular septal perforation( VSP).A 68-year-old man was diagnosed with post-infarction VSP and surgical interveniton was performedby infarct exclusion technique through left ventriculotomy. Residual shunt was observed by left ventriculography,and he developed cardiac failure in spite of medical therapy. Additional surgery for residualshunt was performed 5 months after the initial operation. The VSP was closed with 2 pericardialpatches onto both sides of the septum through right ventriculotomy. Complete closure of the defect wasaccomplished, and no residual shunt was observed by post-operative left ventriculography. The patienthas been doing well with no signs of cardiac failure.
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Source:
胸部外科 64巻12号, 1056-1060 (2011);
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A 78-year-old man referred to our hospital with the chief complaints of anorexia, general malaise, rash,and weight loss. Laboratory examination revealed pancytopenia, hyperglobulinemia, generalized adenopathy,and multiple pulmonary nodules. Video-assisted thoracic surgery (VATS) was performed todiagnose pulmonary nodules. After operation, it was difficult to achieve hemostasis for a while. Finally,the patient was diagnosed as pulmonary cryptococcosis and Evans syndrome.
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臨床と研究
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Source:
胸部外科 64巻12号, 1061-1064 (2011);
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Objective:The left superior vena cava (LSVC) is often complicated with congenital heart defect.Although we simply clamp LSVC during cardio-pulmonary bypass (CPB), appropriateness of this techniquehas not been clarified. We noninvasively evaluate cerebral tissue oxygenation while the clampingof LSVC under CPB by near-infrared spectroscopy( NIRS).Methods:Six children (3 male and 3 female;aged 1.0±0.6 year) undergoing open heart surgerywere studied. The NIRO 300 was incorporated into an established multimodal monitoring system. Tissueoxygenation index (TOI), oxyhemoglobin (O2Hb), and deoxyhemoglobin (HHb) changes wereassessed and compared with LSVC pressure.Results:There were no significant changes in cerebral oxygen delivery after LSVC clamp. LSVCpressure increased from 7.3±1.8 mmHg to 20.1±2.6 just after LSVC clamp, but gradually decreasedwithout any maneuver.Conclusion:These data demonstrated that LSVC could be safely clamped when LSVC pressure wasunder 30 mmHg.
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今月の話題
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Source:
胸部外科 64巻12号, 1065-1069 (2011);
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A 30-year-old man visited a local hospital with the chief complaints of a cough and tightness of thechest. He was found to have an anterior mediastinal tumor, and was referred to our hospital for treatment.He was diagnosed with a large mediastinal tumor, over 15 cm in long diameter, compressing theheart and superior vena cava. The tumor was resected, and diagnosed as a multilocular thymic cyst.He followed an uneventful postoperative course, and was discharged. Later, he re-visited us with severecough and bloody sputum. Despite further evaluation, no definitive diagnosis could be made. Chestcomputed tomography (CT) revealed a mass in the left pulmonary hilum and multiple nodules in theleft lung field. The symptoms rapidly worsened until his death. At autopsy, the left lung lesion wasdiagnosed as hemangiosarcoma. It was also confirmed that the multilocular thymic cyst contained minute germ cell neoplastic( seminomatous) and hemangiosarcomatous components. We speculate thatthe hemangiosarcomatous component arising in association with the seminoma metastasized to the leftlung.
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Source:
胸部外科 64巻12号, 1071-1075 (2011);
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The dual puncture is one of the diseaseful complications at the induction of the epidural anesthesia,which causes severe symptoms of intracranial hypotension such as headache and nausea. The clinicalcourses of 3 patients with the dual puncture symptoms after pulmonary resections were retrospectivelyreviewed, and the effect of the continuous epidural saline infusion treatment (CESI) for the dual puncturewas evaluated. Pneumococcal empyema developed in 1 patient who had been treated with conservative management. In contrast, the symptoms of the others who were treated with the CESI werequickly recovered or were effectively prevented. This report strongly suggested that the CESI wasconvenient and effective treatment for dual punctune symptoms by suppressing the cerebrospinal fluidleakage by elevation of the fluid pressure in the extradural space.
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手術の工夫
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Source:
胸部外科 64巻12号, 1077-1081 (2011);
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We describe a case with pararenal abdominal aortic aneurysm associated with anomalous inferiorvena cava. We applied the technique similar to that employed in the thoracoabdominal aneurysm repairconsisting of mild hypothermic cardiopulmonary bypass and selective visceral perfusion. Replacement ofthe abdominal aorta and reconstruction of the left renal artery were completed without an injury to theanomalous vein.
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Source:
胸部外科 64巻12号, 1082-1085 (2011);
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Segmentectomy including the sequestrated segment and lobectomy are generally performed for intralobarpulmonary sequestration. We report a case of intralobar pulmonary sequestration of Pryce typeIII treated by resection of only the sequestrated segment. A 57-year-old man presented with a 5×3 cmmass shadow overlapping a cardiac shadow on the left lower lung field on chest radiograph at medicalexamination. The mass was not connected with the bronchial tree, and was supplied by an aberrantartery arising from the thoracic descending aorta. The mass was suspected to exist in the normal visceralpleura from chest images. The mass was suspected to be an intralobar pulmonary sequestrationfrom the abovementioned findings, and we performed an operation. At the beginning of the procedure,after dissecting the aberrant artery, only the sequestrated segment was performed.
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臨床経験
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Source:
胸部外科 64巻12号, 1086-1089 (2011);
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A 73-year-old woman with acute aortic dissection( DeBakey typeII) and cardiac tamponade was transferredto our emergency unit. She had a temporary blackout during transfer. An emergency operationwas performed. We started core cooling with the superior vena cava, inferior vena cava, and transapicalaortic cannulation. When the bladder temperature was 30.5 ℃, esophageal temperature was 28.7 ℃, andrectal temperature was 30.5 ℃, the aortic root suddenly ruptured. We changed the arterial cannulationsites from the apex to the dissecting ascending aorta, and the ascending aorta was cross-clamped. However,the patient’s pupils became dilated. Therefore, we started selective cerebral perfusion to avoidprolonged cerebral malperfusion. This procedure took approximately 30 minutes, from the aortic rootrupture to selective perfusion. We performed both aortic root and ascending aortic replacement. Afterthe operation, the patient had no neurological or other organ complications and she was discharged 11days after surgery.
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Source:
胸部外科 64巻12号, 1091-1095 (2011);
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We report a case of adriamycin-induced cardiomyopathy with severe functional mitral regurgitationand congestive heart failure( CHF). Mitral valve replacement( MVR) and papillary muscle approximation(PMA) were effective for this case.A 68-year-old man had adriamycin-induced cardiomyopathy and had required repetitive hospitalizationsfor CHF for the past 10 years. He also required additional CHF hospitalizations after implantationof a device to perform cardiac resynchronization therapy. His echocardiogram showed severe mitralregurgitation and reduced left ventricular function. We performed MVR and PMA for his functionalmitral regurgitation. We preserved the tendinous cords of the anterior and posterior leaflets of themitral valve. His echocardiogram showed improved left ventricular systolic function and reduced leftventricular volume. He has made satisfactory progress after the operation and he has not required furtherhospitalizations for CHF.MVR with preservation of bilateral tendinous cords and PMA are very effective procedures for functionalmitral regurgitation and intractable cardiomyopathy.
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Source:
胸部外科 64巻12号, 1096-1099 (2011);
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The patient was a 60’s-year-old man, who was incidentally pointed out a coin lesion in the right lung bychest radiogram. Chest computed tomography showed a round-shaped, well defined nodule of 2.5 cm insize in the right S1. Positron emission tomography did not show the accumulation of fluorodeoxyglucosein the nodule. We considered the tumor to be benign, but the patient chose surgical treatment. Partialresection of the lung was performed by thoracoscopic surgery. Histopathological diagnosis was humanpulmonary dirofilariasis.
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Source:
胸部外科 64巻12号, 1100-1102 (2011);
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A 77-year-old man who had been treated right pneumothorax by chest tube drainage 2 times visitedour hospital due to dyspnea. He had been treated by home oxygen therapy due to pulmonary silicosis.Chest radiography showed a relapse of right pneumothorax. Video-assisted thoracic surgery was performedand the air leakage point was identified at bullae both of the upper and lower lobe of the lung.When we performed to staple and to resect bullae of the upper lobe, staple dysfunction happened tooccur. Hard nodule in the pulmonary parenchyma was noted by palpation. Since intrapulmonary calcificationof the upper lobe was shown by thoracic computed tomography( CT) prior surgery, the calcifiedlesion thought to be a cause of the staple dysfunction.
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症例
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Source:
胸部外科 64巻12号, 1111-1113 (2011);
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An 80-year-old man was admitted to our hospital for examination of a ball thrombus incidentally foundin the left ventricle (LV). Coronary angiogram revealed severe triple vessel disease and LV dysfunction.Although LV wall motion in the septum and the apex was akinetic, there were no signs of myocardialinfarction. It was diagnosed as an acute LV ball thrombus with hibernating myocardium due toischemia of the left anterior descending coronary artery. Emergency coronary artery bypass grafting(CABG) and excision of the thrombus were performed. Two weeks after surgery, LV functionimproved and the patient was discharged from the hospital without any complication. A LV ball thrombuswithout myocardial infarction is rare, and thought to be caused by hibernating myocardium.
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Source:
胸部外科 64巻12号, 1114-1117 (2011);
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Myotomy or myectomy are well known as the standard treatment of hypertrophic obstructive cardiomyopathy(HOCM), and mitral valve replacement (MVR) is reported to achieve the equivalent therapeuticeffect. And recently, combined treatment with artificial chordae replacement and MVR has beenreported to improve the prognosis.We herein describe a case of a patient with HOCM who developed acute exacerbation of heart failure.The patient was 74-year-old woman, who had been followed by chronic atrial fibrillation (Af) andHOCM for 3 years. The findings at echocardiography included septal hypertrophy, systolic anteriormotion( SAM) of the mitral valve, severe stenosis of left ventricular outflow tract( LVOT), and severemitral valve regurgitation( MR). Calcification of mitral valve was also found. After the medical management,the patient was treated successfully by MVR using a mechanical valve combined with artificialchordae replacement. Maze procedure was also performed for chronic Af. The postoperative coursewas uneventful.MVR combined with artificial chordae replacement could be one of the useful strategies for HOCMassociated with severe MR and organic changes of mitral valve.
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Source:
胸部外科 64巻12号, 1119-1121 (2011);
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A 77-year-old woman who had been treated for tongue cancer, esophageal cancer and laryngeal cancer,25 years, 8 years and 8 months before respectively, was referred to our department because of thepulmonary tumor. Enhanced computed tomography showed a nodule of 32 mm in diameter in the leftupper lobe and persistent left superior vena cava( PL-SVC). She underwent left upper lobectomy withmediastinal lymph node dissection, preserving PL-SVC. PL-SVC is a rare anomaly and may disturb themediastinal lymph node dissection. Care should always be taken for the possibility of anomalous venousconnection in performing thoracic surgery.
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Source:
胸部外科 64巻12号, 1122-1125 (2011);
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82-year-old man was admitted with an abnormal shadow on the chest roentgenogram. Computedtomography showed a 2.8×2.4 cm solid tumor in S3 of the left lung. Transbronchial lung biopsy revealedadenocarcinoma and a left upper lobectomy (ND2a-1) was performed. The tumor consisted mainly oftall columnar clear cells, and no morules were found. Immunohistochemically, the tumor was positivefor α-fetoprotein (AFP) and p53. Accordingly, we made the histological diagnosis of high-grade fetaladenocarcinoma of the lung, pT2N0M0, stage IB. The patient was not received adjuvant therapy andhas been doing well without any tumor recurrence for 3 months postoperatively.
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連載 論文査読者のつぶやき(第4回)
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Source:
胸部外科 64巻12号, 1107-1110 (2011);
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まい・てくにっく
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Source:
胸部外科 64巻12号, 1050-1051 (2011);
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1枚のシェーマ
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Source:
胸部外科 64巻12号, 1070-1070 (2011);
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画像診断Q&A
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Source:
胸部外科 64巻12号, 1103-1106 (2011);
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胸部外科医の散歩道
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Source:
胸部外科 64巻12号, 1118-1118 (2011);
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書評
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Source:
胸部外科 64巻12号, 1076-1076 (2011);
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Source:
胸部外科 64巻12号, 1090-1090 (2011);
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