胸部外科
Volume 65, Issue 9, 2012
Volumes & issues:
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胸部外科の指針
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高齢者難治性気胸の術前危険因子
65巻9号(2012);View Description Hide DescriptionPurpose:In this study, we evaluated the risk factors for postoperative complications in elderly patients with intractable pneumothorax and constructed a risk assessment model. Materials and methods:Between January 2004 and December 2011, 83 elderly patients( age, 75 years or older) underwent an operation at our hospital for intractable pneumothorax. Preoperative factors of these cases were assessed to clarify which is contributory to the development of postoperative complications by using univariate analysis and multivariate logistic regression analysis. Results:Thirty-five patients (42.2%) developed postoperative complications. In univariate analysis, total protein, albumin level, blood urea nitrogen, creatinine level, Paco2, body mass index, performance status, and preoperative respiratory complications showed statistically significant associations with the occurrence of postoperative complications. In the multivariate analysis, the performance status showed a statistically significant association( 95% confidence interval, 1.17〜4.44;odds ratio, 2.28;p=0.0157). Conclusion:The results suggested that the preoperative examinations were useful in predicting postoperative complications in the elderly patients with intractable pneumothorax. Poor performance status, low nutrition, respiratory failure, and preoperative respiratory complications are risk factors for postoperative complications in elderly patients with intractable pneumothorax.
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今月の臨床
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Stanford A 型急性大動脈解離の弓部全置換遠位側吻合における4 点支持パラシュート法
65巻9号(2012);View Description Hide DescriptionObjective:Distal anastomosis in total arch repair for type A acute aortic dissection is difficult because of fragile aortic wall and time-limiting procedure. Until 2008, distal anastomosis was performed with continuous suture technique at 20 ℃, and parachute technique with 4-stay sutures at 26 ℃ was introduced in our institution. This new technique was compared with previous distal anastomosis with continuous suture technique. Methods:From May 1997 to December 2010, 40 patients underwent emergent arch repair for type A acute aortic dissection. Continuous suture technique was used in 23 patients (group C) and parachute technique with 4 stay-sutures was used in 17 patients( group P). Results:Patient’s demographics did not differ between the 2 groups and there was no difference in perioperative or hospital death in the 2 groups. Lower limb ischemic time, cardiac ischemic time, cardiopulmonary bypass time and operation time were significantly shorter in group P. Conclusions:Distal anastomosis using parachute technique with 4-stay sutures in arch repair for type A acute aortic dissection seems to be useful compared with continuous suture technique.
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今月の話題
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流入部中隔欠損を伴う肉柱部中隔全欠損症に対する2 枚パッチ法による心室中隔造成術
65巻9号(2012);View Description Hide DescriptionA 3-year-old girl underwent ventriclar septation using 2 patch technique. Echocardiography at birth revealed single left ventricle with pulmonary hypertension. Pulmonary artery banding was performed at the age of 1 month. Echocardiography at the age of 3 years showed total inlet-trabecular septal defect. Ventricular septation was performed through the right atrium. The tendon of Todaro and the coronary sinus were in normal positions. Almost all of the inlet septum and trabecular septum were deficit, although the posterior median ridge was present. It was considered that the atrio-ventricular node was shifted inferiorly and the conduction system ran down the inlet septum as in the case of atrioventricular septal defect, since this patient had concordant atrioventricular( AV) connection. It was difficult to form the septum using a single patch because of complicated anatomy. Thus we decided to divide the patch in order to make smooth surface avoiding conduction injury. One patch was used for the trabecular defect using running sutures and another patch was used for the inlet defect using pledgeted mattress sutures. Eventually both patches were sutured together to close the defect. Regular sinus rhythm resumed, although 2:1 AV block appeared temporally. The patient was discharged at postoperative day 30 without any complication. -
難治性気胸のため上葉切除を余儀なくされた肺癌
65巻9号(2012);View Description Hide DescriptionA 76-year-old man with dyspnea and left side chest pain was admitted to our hospital. Chest roentgenogram showed a left side pneumothorax. Chest computed tomography( CT) showed a mass shadow in S3 and a nodular shadow in S10 of left lung. Drainage of the pleural cavity and a trans-bronchial biopsy was performed, and primary lung adenocarcinoma was diagnosed. Abdominal CT showed a left enlarged adrenal gland. Because pneumothorax was resistant to the treatment by closed drainage, a surgical treatment was performed. Since the main tumor of left upper lobe was adjacent to emphysematous bullae, simple bullectomy was not possible. Accordingly, left upper lobectomy, partial resection of left lower lobe and lymph node dissection were performed. Positron emission tomography( PET)-CT after surgery strongly suggested adrenal gland metastasis and the pathological stage Ⅳ was established in combination with the histopathological examination. Appropriate surgical approach must be considered even for case with the advanced lung cancer, like present case.
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手術の工夫
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胆道鏡を血管内視鏡として用いたハイブリッド手術
65巻9号(2012);View Description Hide DescriptionWe performed hybrid operation on a 3-year-old boy with thrombosis in the pulmonary arterial conduit which had been implanted concomitantly at the time of Fontan operation. We used a cholangioscope as a substitute of intravascular endoscope. It visualized the organized thrombus and the suture line in the conduit. Hybrid operation was successfully performed based on the detailed findings gained by cholangioscopy. -
炭酸ガス送気装置を用いた胸腔鏡下拡大胸腺摘出術
65巻9号(2012);View Description Hide DescriptionA 40-year-old woman with generalized myasthenia gravis was scheduled for extended thymectomy. The patient under general anesthesia with double-lumen intubation was placed in the supine position. A sealed 5 mm trocar and 2 sealed 12 mm trocars were inserted through the 3rd, 4th and 5th intercostal space at the both side of the anterior axillary line. Under carbon dioxide insufflations by positive pressure of 7 mmHg, thymus and fat tissue was resected completely. An operation time was 162 minutes, and blood losses during operation were 5 ml. The present method was thought to be safe and useful for conducting extended thymectomy.
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臨床経験
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弓部大動脈瘤破裂に対するchimney グラフトと頸部分枝バイパス術併用ステントグラフト内挿術
65巻9号(2012);View Description Hide DescriptionAn 83-year-old man with a decreasing level of consciousness was carried to the emergency room. Computed tomography (CT) revealed a ruptured aortic arch aneurysm. He was deemed a high risk candidate for conventional surgical repair. The case was treated by a hybrid approach. Endo-exclusion of thoracic aortic aneurysm (TAA) was obtained by implanting stentgrafts from the ascending to descending aorta. The brain circulation was maintained by right to left carotid and to left subcravian artery bypasses combined with“ chimney endo-debranching graft” of the innominate artery. This could be a method of choice for the acute patients under similar circumstances. -
拡張型心筋症に対する心臓再同期療法と両弁尖温存僧帽弁置換術施行後の運動耐容能
65巻9号(2012);View Description Hide DescriptionIt has been reported that cardiac resynchronization therapy( CRT) improves cardiac systolic function and reverses cardiac remodeling by correcting intra- and interventricular asynchrony, and that mitral valve replacement (MVR) with bileaflet preservation dose not impair left ventricular systolic function through preserving the continuity of the mitral complex.The present report describes a case of a 68-year-old female with severe chronic heart failure and mitral valve regurgitation due to end-stage dilated cardiomyopathy who showed improved exercise tolerance following CRT and MVR with bileaflet preservation. Based on this case, we considered that the combination therapy of CRT and MVR with bileaflet preservation might be one of the effective strategies for severe chronic heart failure and mitral valve regurgitation due to end-stage dilated cardiomyopathy. -
肺腫瘍との鑑別が困難であった腎移植後肺クリプトコッカス症
65巻9号(2012);View Description Hide DescriptionA 61-year-old man, with a history of renal transplant for immunoglobulin A (IgA) nephropathy and surgery for advanced gastric carcinoma, was noted to have a nodular shadow of 1.3 cm in diameter in the left lung( S8) based on chest computed tomography( CT), and was suspected to have primary pulmonary carcinoma or a metastatic pulmonary tumor, for which surgical resection was performed. A rapid pathological diagnosis of inflammatory granuloma was made, and the patient was finally diagnosed as having pulmonary cryptococcosis based on the histopathology, and received fluconazole postoperatively. Patients with organ transplant history showing a nodular shadow in the lung should undergo a careful workup in consideration of both malignant tumor and infection. -
肺扁平上皮性乳頭腫
65巻9号(2012);View Description Hide DescriptionWe report a rare case of pulmonary squamous papilloma. A 42-year-old woman was referred to our hospital complaining of dry cough. A chest computed tomography (CT) showed a mass shadow in the lower lobe of left lung. Serum concentrations of carcinoembryonic antigen (CEA) and squamous cell carcinoma-related antigen (SCC) were elevated to 13.0 ng/ml and 11.8 ng/ml, respectively. The mass was positron emission tomography( PET)-positive, with a maximum standard uptake value( SUVmax) of 11.55, suggesting a malignant neoplasm. Under the guidance of video-assisted thoracoscopy, left basal segmentectomy was performed. Intra-operative diagnosis was a squamous papilloma and no malignancy. Her postoperative course was uneventful. She is currently alive without any sign of recurrence.
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症例
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左冠状動脈主幹部病変を合併した異型大動脈縮窄症の1 例
65巻9号(2012);View Description Hide DescriptionA 60-year-old male was referred to our institution for investigation of intractable hypertension. Coarctation of the aorta was detected by computed tomography (CT). Bilateral internal thoracic arteries played an important role as a collateral source to the lower extremity. Coronary angiography showed stenosis at the ostium of left main trunk. Ascending aorta to bilateral external iliac artery bypass grafting and off-pump coronary artery bypass grafting (OPCAB) was done simultaneously, this is because we had to harvest left internal thoracic artery as a conduit for coronary artery bypass grafting(CABG).Postoperative course was uneventful. The patient was discharged 10 days after the operation. We could perform less-invasive surgery despite the simultaneous operations. -
リング付き人工血管内挿術後26 年目に再手術を要した1 例
65巻9号(2012);View Description Hide DescriptionA 61-year-old female, who had undergone the surgical treatment of acute type A aortic dissection with a ringed intraluminal graft 26 years before, presented with breathlessness. Computed tomography (CT) showed peri-prosthetic leakage and enlargement (45×50 mm in diameter), enlargement of the aortic root (42 mm in diameter), and aneurysm of the ascending aorta and the aortic arch (55 mm in diameter) with chronic type A aortic dissection. Echocardiography showed severe aortic regurgitation. She successfully underwent aortic root replacement( Bentall procedure) and total arch replacement. -
左開胸による心膜部分切除により改善した滲出性収縮性心膜炎の1 例
65巻9号(2012);View Description Hide DescriptionA 72-year-old male was admitted to our hospital due to high fever and dyspnea. Echocardiography and bacterial culture of pericardial fluid revealed purulent pericarditis caused by Streptococcus. Despite pericardial drainage and antibiotic therapy, hemodynamic instability due to constriction persisted. At 12th hospital day, partial pericardiectomy with left thoracotomy was performed. After the operation, his hemodynamics improved gradually, and was discharged from the hospital on the 54th post operative day without recurrence of infection nor constriction. -
同一肺葉内同時性三重多発肺癌の1 例
65巻9号(2012);View Description Hide DescriptionA 78-year-old female was referred to our department due to 3 abnormal shadows in the left lower lobe, that were S6, S8 and S10 by chest computed tomography (CT). Bronchoscopy was performed, but definitive diagnosis was not obtained. The result of surgical biopsy for S10 nodule was squamous cell carcinoma and left lower lobectomy with lymph node dissection was performed. Other 2 lesion were both adenocarcinoma with mixed subtypes. According to the criteria of Warren and Gates, and Martini, these 3 carcinomas were all primary lung cancers. -
完全鏡視下に切除した食道重複嚢胞の1 例
65巻9号(2012);View Description Hide DescriptionDuplication of the alimentary tract is a developmental anomaly, which may affect any part of the digestive tract from the mouth to the anus. Esophageal duplication cyst is caused by an incomplete differentiation of the foregut. We report a case of esophageal duplication cyst resected using video-assisted thoracic surgery (VATS). Chest radiography of a 23-year-old woman showed an abnormal shadow. Chest computed tomography (CT) indicated a cystic lesion adjacent to the descending aorta and the esophagus. Magnetic resonance imaging (MRI) showed that the cystic lesion was filled with protein-rich fluid. The lesion was resected using VATS, and it was pathologically diagnosed to be an esophageal duplication cyst. -
嚥下困難感を主訴に発見された中縦隔迷走神経由来神経鞘腫の1 例
65巻9号(2012);View Description Hide DescriptionA 41-year-old male complaining of difficulty in swallowing was referred to our hospital. Chest computed tomography( CT) demonstrated 34×25×36 mm tumors in the subcarinal region. Gadolinium( Gd)-diethylenetriamine pentaacetic acid( DTPA) enhanced magnetic resonance imaging (MRI) showed the tumor with the target appearance sign, i.e., signal intensity of the mass was low on T1-weighted MRI, and the center of the mass was enhanced by Gd-DTPA. A neurogenic tumor was suspected on radiological findings. Resection of the tumor by video-assisted thoracoscopic surgery was performed. The tumor was found to originate from the left vagus nerve by operative findings and was diagnosed as schwannoma by pathological examination.
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連載 胸部外科医の生活を楽にするiPad の利用 (第1回)
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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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