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胸部外科の指針
(池田宜孝)
p.
89–97(9)
詳細を表示する詳細を表示する
- Background：Surgical ventricular restoration （SVR） is considered as an effective surgical procedure for patients with ischemic myocardiopathy（ ICM）. However“ surgical treatment for ischemic heart failure （STICH）” trial concluded that adding SVR to coronary artery bypass grafting （CABG） did not relieve symptoms and failed to lower death rate or cardiac rehospitalization as compared with CABG alone. Aim：The aim of this study was to investigate the efficacy of CABG with SVR for ICM. Methods and results：We retrospectively studied 24 patients who had undergone CABG with or with out SVR for ICM from October 1992 to June 2008. In CABG with SVR group, cardiac symptoms were relieved and the left ventricular end-systolic volume index （LVESVI） was reduced from the baseline significantly. However cardiac symptoms were relieved only in CABG-S ［left ventricular end-diastolic dimension （LVDd）＜60 mm］ group, and not in CABG-L （LVDd≧60 mm） group. LVESVI was not reduced in CABG without SVR group. Conclusion：SVR contributed to relieving the symptoms, and improving the left ventricular function and the long-term survival of patients with especially dilated ICM, which could not be achieved by CABG alone.
今月の臨床
(上原麻由子)
p.
98–102(5)
詳細を表示する詳細を表示する
- A 61-year-old man with acute myocardial infarction underwent percutaneous coronary intervention with stent for the left main coronary artery （LMT） and the left anterior descending artery （LAD）. Three months later, we recognized the LMT aneurysm complicated with possible thrombus formation, which developed in size during 6 months. In addition, the LAD stent showed significant in-stent stenosis. For the purpose of supplying blood flow to the distal of LAD, and avoiding myocardial infarction due to distal thrombosis possibly originated from LMT aneurysm, we decided to perform surgical operation. On preoperative examination, this patient had an obstruction of the right internal carotid artery. Although the direct repair of LMT anerysm requires conventional approach with cardiopulmonary bypass, we applied off-pump coronary artery bypass grafting（ OPCAB） considering the risk of cerebrovascular event. Consequently, OPCAB was performed in usual fashion ［right internal thoracic artery （RITA） -LAD, left internal thoracic artery-left circumflex artery （LITA-LCX）］ followed by the ligation of the proximal of LAD and LCX without cardiopulmonary bypass. The patient had a good operative course.
(谷口大輔)
p.
103–107(5)
詳細を表示する詳細を表示する
- We retrospectively reviewed cases of acute empyema treated surgically in our hospital from April 2005 to April 2010. Patients comprised 10 men and 4 women, with a mean age of 62.5 years（ range, 23〜 80 years）. One case required open thoracotomy and decortication, and was in the organized phase at the time of operation（ duration of symptoms before surgery, 44 days）. The remaining 13 cases were in the fibropurulent phase at the time of operation and underwent video-assisted thoracoscopic surgery （VATS）. In 6 of these 13 remaining cases, we performed mini-thoracotomy combined with the thoracoscopic operation due to the presence of severe intrathoracic adhesions. Median durations of postoperative drainage and postoperative stay were 5 days（ range, 2〜7 days） and 13.5 days（ range, 6〜17 days）, respectively. Postoperative complications of subcutaneous abscess, drug-induced hepatitis, pseudomembranous enterocolitis and reexpansion pulmonary edema were observed in 1 case each, but all patients survived to discharge without perioperative deaths. VATS is a safe and effective method for the management of acute empyema, and is favorable to perform in the fibropurulent phase. Appropriate combination with mini-thoracotomy was useful in accomplishing surgery in cases with dense adhesion.
臨床と研究
(榎本直史)
p.
110–114(5)
詳細を表示する詳細を表示する
- We have evaluated the usefulness of off-pump coronary artery bypass grafting （CABG）［OPCAB］. The subjects were 153 patients who underwent isolated CABG between May 2005 and May 2009. They were divided into 2 groups（ on-pump/arrest；ON group：76 subjects vs OPCAB；OFF group：77 subjects）. The concomitant conditions, the number of bypasses, the postoperative outcome and the early graft patency rate were compared between the 2 groups. The mean age and the incidence of carotid artery lesions were significantly higher in the OFF group. The number of bypasses was significantly smaller in the OFF group. The postoperative intubation time and the length of postoperative hospitalizationwere significantly shorter in the OFF group. Concerning major postoperative complications, mediastinitis, cerebral infarction or bleeding was not observed in the OFF group. There was no hospital death in the OFF group. The early graft patency rate with saphenous vein graft （SVG） was significantly lower in the OFF group. Early stage extubation was achieved by the introduction of OPCAB. In some occasions, however, the target site could not be reached with OPCAB, and furthermore, the quality of anastomosis was poor. In order to achieve complete revascularization, therefore, on-pump/arrest surgery should be considered in some cases.
今月の話題
(鎌田 誠)
p.
115–118(4)
詳細を表示する詳細を表示する
- A 55-year-old man was diagnosed with infective endocarditis（ IE） of the mitral valve caused by Streptococcus sanguinis. His IE was controlled immediately after the initiation of intravenous antibiotic therapy lasting for 4 weeks. A few days before surgery, he complained of abdominal discomfort and computed tomography （CT） scan revealed rupture of the mycotic iliocolic artery aneurysm. Emergency transcatheter arterial embolization（ TAE） was successfully conducted. After additional 4 weeks’ intravenous antibiotic therapy, the mitral valve was replaced. Mycotic visceral artery aneurysms are rare in IE. Early diagnostic approaches and interventions such as TAE are crucial.
(森脇義弘)
p.
119–123(5)
詳細を表示する詳細を表示する
- Forty eight year-old woman with untreated liver cirrhosis was transferred to our critical care and emergency center because of airway crisis due to retropharyngo-esophageal hematoma after slight chest contusion. We performed emergency tracheal intubation beyond stenotic part of the trachea. The hematoma did not diminished in a few days. Although we considered tracheostomy, we hesitated to perform conventional median tracheostomy because of the risk of complication of infection of the hematoma which might require drainage or removal resulting in contamination between tracheostomy site and cervical wound. We performed paramedian tracheostomy by antero-lateral skin incision to avoid these risks. Fortunately, the patient did not require drainage of the retropharyngo-esophageal hematoma. Paramedian tracheostomy should be taken into account for patients with presumably contaminated cervical wound.
(清水 恵)
p.
125–127(3)
詳細を表示する詳細を表示する
- A 56-year-old woman admitted to our hospital because of injury by a road accident. A chest X-ray film and computed tomography （CT） scan showed multiple left rib fractures, hemothorax in the left pleural cavity, and obscurity of the left diaphragm. The stomach and injured spleen were also shown to shift to the left thoracic cavity. The patient was diagnosed as having diaphragmatic rupture with hemothorax in the left pleural cavity due to splenic injury. Emergent surgery was performed and massive bleeding was observed in the thoracic and abdominal cavities. After performing splenectomy and replacing the stomach in the abdominal cavity, the diaphragm was repaired. The patient was discharged 66 days after the surgery. Since traumatic diaphragm rupture can lead to hemorrhagic shock associated with injuries to adjacent organs, it is important to establish an accurate diagnosis and to performed appropriate surgical treatment without delay.
手術の工夫
(黒木秀仁)
p.
128–131(4)
詳細を表示する詳細を表示する
- A 78-year-old female presented at a nearby hospital with hemorrhage and loss of consciousness. After examination by computed tomography （CT） scan, she was referred to our hospital on suspicion of an impending rupture of the descending thoracic aorta aneurysm. She underwent a 2 stage operation. At the 1st operation, graft replacement of the descending aorta and closing of the aneurysmal wall over the aortoesophageal fistula were performed. On the 2nd postoperative day, intrathoracic esophagogastrostomy was performed by the gastric tube interposition technique. On the 54th postoperative day, she was discharged to a rehabilitation hospital.
(石田 格)
p.
132–135(4)
詳細を表示する詳細を表示する
- We report a case of a giant intrathoracic tumor successfully resected via clamshell incision and lower door open thoracotomy. A 62-year-old woman presented with cough and dyspnea on exertion. A chest computed tomography （CT） revealed a giant mass occupying nearly whole of the right hemithorax. Since the tumor infiltrated deeply into the lung parenchyma, we performed a right pneumonectomy. The 1st thoracotomy was performed at 4th intercostal clamshell incision. Then we divided lower sternum vertically and opened the right lower chest wall laterally. These procedures provided wide operative view from the apex to the diaphragm and excellent access to hilar constructions, and enabled enbloc resction of giant tumor with the right lung. The resected specimen was 25×19×12 cm in size, 2,830 g in weight, and histologically diagnosed as a malignant solitary fibrous tumor. We conclude that this approach is effective for excision of giant intrathoracic tumor.
臨床経験
(古川博史)
p.
136–140(5)
詳細を表示する詳細を表示する
- An 81-year-old man had a history of Takotsubo cardiomyopathy induced by general fatigue after travel and acute gastritis 2 years previously. Recently, dyspnea on effort had been worsening. Since preoperative echocardiography showed severe aortic valve regurgitation （AR） with left ventricular （LV） dilatation, aortic valve replacement （AVR） by the standard procedure was indicated. Since the safety of the perioperative clinical course including recurrence of Takotsubo syndrome and hemodynamic compromise was unclear, a thorough examination was performed before surgical intervention. AVR with a 21 mm Mosaic bioprosthesis was performed. Transesophageal echocardiography （TEE） during operation did not demonstrate any sign of Takotsubo syndrome and good LV function was maintained. The patient was discharged on postoperative day 18 without any cardiac events including arrhythmia or clinical symptoms such as chest pain. Based on these results, open heart surgery under cardiopulmonary bypass （CPB） and cardiac arrest could be safely performed in patients with a history of Takotsubo cardiomyopathy with minimum use of cardiac agents including cathecholamine and sufficient perioperative removal of emotional and physical stress
(上林孝豊)
p.
141–144(4)
詳細を表示する詳細を表示する
- A 74-year-old man underwent right upper lobectomy for the lung cancer and bullectomy of right lower lobe. Fibrin sealant was used for sealing the excision line. The increase of the pleural effusion with increasing C-reactive protein（ CRP） and eosinophilia was noted at the 17th day after the operation. The pleural effusion was transparent and yellowish colored suggesting transudatory liquid. The eosinophil in the pleural effusion was as high as 14％. The drainage of the pleural effusion was performed for 2 days resulting in disappearing the abnormal accumulation without any additional treatment. The cause of pleural effusion was supposed to be fibrin sealant by a positive result of the drug lymphocyte stimulation test.
症例
(岡田修一)
p.
155–157(3)
詳細を表示する詳細を表示する
- We report a case of a 51-year-old man presenting with pseudoaneurysm associated with a knitted Dacron patch used to repair coarctation of the aorta. At the age of 15 years, he underwent patch angioplasty for coarctation of the aorta. However the computed tomography（ CT） scan, taken after 36 years, demonstrated pseudoaneurysm of the thoracic aorta at the anastmotic site. He was treated by endovascular stent graft using Gore-TAG 3115. His postoperative course was uneventful. Follow-up CT scan demonstrated no recurrence of pseudoaneurysm.
(大橋伸朗)
p.
158–160(3)
詳細を表示する詳細を表示する
- Persistent 5th aortic arch （PFA） is a rare congenital cardiac anomaly that was firstly reported by Van Praagh et al, in 1969. A 3-month-old boy was referred to us with no symptom but heart murmur. Cardiac echocardiography and the following 3-dimensional computed tomography （3D-CT） scan revealed PFA with coarctation of aorta. There was pressure gradient of 50 mmHg between upper and lower limbs. He was carefully observed at the outpatient clinic because of no afterload mismatch. At the age of 9 months, coarctectomy and end-to-end anastomosis was performed between the PFA and distal arch below left vertebral artery. A histological examination of resected tissue revealed the thickened intima and rough elastic fiber that is absolutely different from normal aorta. Careful observation is necessary with the possibility of future aneurysmal change or re-coarctation, although the postoperative course has been so far uneventful.
(中村 賢)
p.
161–164(4)
詳細を表示する詳細を表示する
- We report a rare case with severe intestinal ischemia due to chronic aortic dissection. A 75-year-old man was admitted to our hospital with abdominal and right leg pain. The patient had a history of aortic dissection （Stanford type B） 12 years before admission and had been treated medically. Although a throaco-abdominal aneurysm due to aortic dissection （Crowford type Ⅲ） had been diagnosed 1 year before admission, he had rejected the operation. Computed tomography （CT） revealed an increased diameter of the aneurysm （6 cm）. As abdominal pain was increased, emergent surgery was performed on day 1 after admission. Although perfusion of the superior mesenteric artery and marginal artery was maintained, intestinal ischemia was worsening and general condition was deteriorated during surgery. Bypass surgery and/or resection of colon were not indicated because of peripheral colon artery ischemia, and he expired day 1 after surgery.
(宮津克幸)
p.
165–167(3)
詳細を表示する詳細を表示する
- A 70-year-old male underwent left pneumonectomy for lung cancer in November 2008. Although he was diagnosed as pT2bN1M0 （stage ⅡB） after the operation, adrenal metastasis was found 8 months later. Positron emission tomography （PET） revealed accumulation in the adrenal gland and rectum. Gastrointestinal tract examination revealed a type 1 tumor in the rectum. Histological examination of biopsy specimens obtained from the lesion suggested papillaryadenocarcinoma of rectum. Abdominoperineal resection was performed. The resected rectal tumor was reported immunohistochemically as metastasis from primary lung cancer.
(環 正文)
p.
169–171(3)
詳細を表示する詳細を表示する
- A 61-year-old female was diagnosed as having end-stage renal failure developed dyspnea soon after introduction of continuous ambulatory peritoneal dialysis （CAPD）. Chest X-ray showed a right-side massive pleural effusion. Pleuroperitoneal communication was suspicious, because the hydrothorax significantly improved by the stop of CAPD. We performed video-assisted thoracic surgery. Using indigocarmine containing peritoneal dialysis fluid through a CAPD catheter, we found a fistula on the diaphragm from which blue dialysis solution flowed out like a fountain. The fistula of the diaphragm was directly closed with a surgical stapler and covered using cellulose oxidized （Surgicel） and fibrin glue. She could restart CAPD on postoperative days 7, and no recurrence of hydrothorax has been detected for 10 months after surgical treatment.
連載 胸部外科における創閉鎖の最新知見―SSI・肥厚性瘢痕の予防から胸骨癒合まで―(第1回：新連載)
(小川 令)
p.
149–154(6)
詳細を表示する詳細を表示する
- Wound condition changes from moment to moment. It is important to understand what is happening on the wound to evaluate and treat it. Wound can be classified into low contaminated wound, contaminated wound, colonized wound, critical colonized wound and infected wound by status of bacteria on the wound. Moreover, it can be classified into acute wound, subacute wound, subchronic wound, and chronic wound by time course. Also, wound healing course can be classified into coagulation phase, inflammation phase, proliferation phase and remodeling phase. Moreover, wound healing can be classified into primary wound healing, secondary wound healing and tertiary wound healing according to types of surgical intervention. The TIME principles provide a systematic approach to the management of wounds. TIME leads to an optimal wound bed preparation（ WBP）. The objectives underpinning TIME are tissue non-viable or deficient （T）, infection or inflammation （I）, moisture imbalance （M） and epidermal margin；non advancing or undermined（ E）
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胸部外科医の散歩道
