Volume 65,
Issue 13,
2012
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胸部外科の指針
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Source:
胸部外科 65巻13号, 1105-1111 (2012);
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To minimize the risk of malperfusion, axillary arterial cannulation which avoids retrograde flow, has been widely used in patients undergoing operations for various types of aortic pathologies. Despite several advantages of this technique, cerebral malperfusion is getting known and might be due to newly developed arterial damage or dissection. Eighty-four patients underwent cannulation of the axillary artery in recent 5 years. Malperfusion occurred in 3 patients with significant regional cerebral oxygen desaturation during operation. Axillary arterial perfusion was stopped and oxygen saturation was elevated immediately. The perfusion was switched to the femoral artery and following procedure was completed. Although axillary arterial cannulation is an attractive alternative, neither axillary nor femoral arterial perfusion is perfect to avoid the cerebral malperfusion. Whichever perfusion site is used, special care should be taken for intraoperative finding and appropriate use of each techniques.
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今月の臨床
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Source:
胸部外科 65巻13号, 1114-1118 (2012);
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Tracheo-innominate artery fistula (TIF) is a rare but fatal complication after tracheostomy. Necessary lifesaving measures include proper ventilation, temporary hemostasis, and surgery. Recently, we successfully managed 3 cases of TIF. Ventilation and temporary hemostasis were secured by a long endotracheal tube and overinflated cuff. Division of the innominate artery, restoration of the tracheal fistula with an autologous pericardial patch or direct closure, and aorto-innominate bypass grafting or extra-anatomical bypass grafting with a polytetrafluoroethylene (PTFE) graft were performed through an emergency median sternotomy. All 3 patients recovered with no problems. After TIF occurs, the patient’s condition rapidly worsens, and the risk of bacterial contamination in the operative field may increase. Surgical intervention should be performed for patients with tracheal stenosis who are judged to be at high risk for TIF. This preventive surgery includes bypass grafting to divide the innominate artery and partial resection of the anterior bony thorax(upper sternum, medial part of clavicles, and anterior part of upper ribs if necessary). We believe that this procedure will improve tracheal stenosis and minimize the risk of TIF. Thus far, 10 patients have undergone this operation, and their mid-term results are satisfactory.
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今月の話題
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Source:
胸部外科 65巻13号, 1119-1122 (2012);
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A Jehovah’s Witness who requires thoracic and cardiovascular surgery represents a challenge to both the surgeon and the patient because of the patient’s refusal to accept blood transfusion. We reported 15 cases of Jehovah’s Witness patients from 43 to 80 years of age who underwent cardiac operations or thoracic vascular operations. There was 1 emergency operation case and 2 re-do operation cases. Erythropoietin and serum albumin injections were allowed to be used in some cases. The mean pre-operative haemoglobin level in these patients was 12.3 g/dl. The mean postoperative lowest haemoglobin level was 9.2 g/dl. The mean haemoglobin level at the point of leaving hospital was 11.4 g/dl. There were no postoperative complications and no operative deaths. We successfully performed the thoracic and cardiovascular operations on Jehovah’s Witnesses, including emergency cases, safely without blood transfusion. The most important thing is a careful and safe operative technique which reduces perioperative bleeding as much as possible.
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Source:
胸部外科 65巻13号, 1123-1126 (2012);
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A 77-year-old woman was admitted to our hospital with abnormal chest shadow detected on a medical checkup. Chest computed tomography(CT)showed a well-defined tumor in the upper lobe of the right lung. On positron emission tomography by fluorodeoxyglucose(FDG),the tumor revealed to be positive. We performed right upper lobectomy with hilar and mediastinal lymph node dissection. The histopathological diagnosis was lymphoepithelioma-like carcinoma (LELC). In the past 25-years, 41 cases have been reported in Japan. The average age is 64 years old, including 25 male cases and 16 female cases. Among these cases, more than half were in the early resectable stage.
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Source:
胸部外科 65巻13号, 1127-1130 (2012);
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Case:The patient was a 17-year-old girl. She underwent treatment for osteosarcoma when she was around 10 ~ 11 years old. A follow-up chest computed tomography(CT) revealed one small pulmonary nodule 6 years later. The orthopedist thought it was metastasis. The patient was referred to our division and treated with thoracoscopic partial resection. The final pathological diagnosis was a primary lung adenocarcinoma. Conclusion:This case is unique because the patient is juvenile and had a history of another cancer, i.e., osteosarcoma. Her primary lung cancer is a 2nd malignancy. The incidence of 2nd malignant neoplasm is one of the significant late effects of pediatric cancer treatment. When pulmonary lesions are detected in young patient with histories of neoplasms, primary lung cancer as a 2nd malignant neoplasm as well as pulmonary metastasis from 1st neoplasm, should be considered as differential diagnosis.
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手術の工夫
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Source:
胸部外科 65巻13号, 1131-1134 (2012);
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A 63-year-old male patient was admitted to the hospital complaining of chest pain. He had undergone aorto-bifemoral bypass and percutaneous coronary intervention due to Leriche syndrome and ischemic heart disease. Radiological examination revealed complete obstruction of the right coronary artery(#2) as well as the bypass graft. He was successfully treated with the simultaneous operation of coronary artery bypass grafting( CABG) and ascending aorta to bifemoral artery bypass.
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Source:
胸部外科 65巻13号, 1135-1138 (2012);
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Congenital bicuspid aortic valve (BAV) is one of the most common congenital heart diseases, with a high incidence of associated valvular lesions and aortic abnormalities including aortic stenosis( AS), aortic regurgitation, aortic dilatation, and aortic dissection. Patients with BAV and AS often have a small aortic annulus. We encountered a case of BAV in which a 51-year-old woman with severe AS having a small aortic annulus and a dilated ascending aorta required surgical intervention. We performed the surgery using new technique that involved concomitant replacement of the aortic valve and the ascending aorta with enlargement of the aortic annulus using a single uniquely-shaped graft to avoid prosthesispatient mismatch. We trimmed the proximal end of the straight graft in shape of 2 teardrops hanging on it to fit the cut annulus. It requires only a single suture line to replace the ascending aorta and enlarge the aortic annulus, which entails a decreased risk of bleeding during surgery. We believe that it could be applicable to many cases requiring concomitant surgery.
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Source:
胸部外科 65巻13号, 1139-1141 (2012);
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Effective surgical treatment for spontaneous pneumothorax requires control of the postoperative recurrent bulla. Currently, a covering method using an absorbable sheet is a well-recognized form of operative procedure to prevent recurrence. However, the technique used in covering methods appears to be complicated. Here, we present a simple covering method. Using a suture as a guide, we can easily and correctly induce the sheet to the targeting area. Fixation is made at only 1 point at the center of the sheet. To date, we have applied this covering method to 57 patients. Recurrence was recognized in 3 patients( 5.3%) over a mean follow-up period of 12 months.
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臨床経験
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Source:
胸部外科 65巻13号, 1143-1146 (2012);
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Cardiac papillary fibroelastoma is an uncommon tumor, and especially the one located in the left ventricular outflow tract wall is rare. The patient is a 69-year-old female. Multi-detector-row computed tomography (MDCT) revealed a 20×15 mm tumor attached to the left ventricular outflow tract wall under the left coronary cusp. The tumor was surgically removed with a slight margin. The tumor was milk-white in color, and had an egg-like appearance. The histological findings revealed papillary fibroelastoma. The postoperative course was uneventful.
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Source:
胸部外科 65巻13号, 1147-1149 (2012);
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A 65-year-old male was referred to our department because of an abnormal shadow on chest X-ray. He had been suffering from rheumatoid arthritis for 10 years. He had been treated with tumor necrosis factor antagonist(etanercept)for the past 3 years and 6 months. Computed tomography of the chest revealed an irregular shaped pulmonary nodule with the longest diameter of 4.3 cm in the left upper lobe. The diagnosis of lung carcinoma was made. He underwent video-assisted left upper lobectomy with lymph node dissection. Histological examination revealed poorly differentiated squamous cell carcinoma. The tumor was classified as stage ⅢA with T4(pm2)N1M0. No adjuvant chemotherapy was performed because he had recurrent arthralgia after operation and new anti-rheumatic-drug was required. He is free from disease with a follow-up period of 11 months.
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Source:
胸部外科 65巻13号, 1150-1153 (2012);
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We experienced a rare case of a 76-year-old man with an anterior mediastinal tumor diagnosed postoperatively as atypical thymic carcinoid with hypercalcemia. He was found to have a growing abnormal mediastinal shadow, and admitted. Chest computed tomography scan on admission revealed an anterior mediastinal mass of 4.0 cm in diameter. Extended total thymectomy was performed through a median sternotomy. The histopathological diagnosis was an atypical carcinoid of the thymus. He received adjuvant mediastinal irradiation. Endocrinological tests for preoperative hypercalcemia revealed high levels of serum intact-parathyroid hormone( PTH), prolactin and gastrin. A parathyroid scintigraphy revealed a parathyroid tumor. He has been well without any sign of recurrence for 1 year after surgery and irradiation treatment. When diagnosing anterior mediastinal tumor with hypercalcemia, atypical carcinoid of thymus with hyperparathyroidism should be considered.
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症例
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Source:
胸部外科 65巻13号, 1165-1168 (2012);
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A 74-year-old female who had been on hemodialysis for 4 years developed congestive heart failure. Severe mitral valve stenosis and tricuspid regurgitation were thought to be causes of her heart failure. She underwent a replacement of severely calcified mitral valve and an annuloplasty of tricuspid valve. We excised both mitral leaflets, however, just a 21 mm sizer could pass through the annulus. Because posterior annular calcification was so severe we could not palace sutures. Therefore, we placed noneverted horizontal mattress sutures from the left ventricle to the atrium on the anterior annulus, and everted horizontal mattress sutures on the posterior left atrial wall. A crescent-shaped felt patch was sutured to the posterior left atrial wall for annular reconstruction. Then the prosthetic valve was fixed onto this felt patch, resulting a 25 mm ATS valve was seated successfully at a supraannular position. Although the patient died from a sepsis on postoperative day 14, the prosthetic valve functioned normally without any perivalvular leakage.
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Source:
胸部外科 65巻13号, 1169-1171 (2012);
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A 3-month-old boy was transferred to our hospital because of a cardiac tumor in the right heart, which had been prenatally diagnosed by fetal echocardiography. During the operation, the tumor was found on the Chiari’s network in the right atrium. The tumor was excised and the ventricular septal defect was repaired. Postoperative histological examination revealed that the tumor was a papillary fibroelastoma. He was transferred to a pediatric unit for postoperative care.
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Source:
胸部外科 65巻13号, 1173-1176 (2012);
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Coronary aneurysms in adults are rare. The natural history of such coronary aneurysms is unknown. Surgical treatment is often concomitant with the treatment of obstructive coronary lesions. However, the ideal treatment strategy is poorly defined. We herein present a case of successful treatment of a large coronary artery aneurysm with interposition of a reverse saphenous vein graft. This modality offers important benefits over other currently used surgical and percutaneous techniques, and should be considered as an effective option.
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Source:
胸部外科 65巻13号, 1177-1179 (2012);
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True left ventricular aneurysms are thought to arise from the expansion and thinning of the transmural infarct area, whereas false aneurysms result from containment of ventricular rupture by pericardial adhesions. We reported a case of true left ventricular aneurysm with pseudoaneurysm( mixed type aneurysm) which was treated surgically.
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Source:
胸部外科 65巻13号, 1180-1183 (2012);
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A 38-year-old woman was referred to our hospital because she presented with an abnormal shadow on a chest radiograph. A through examination showed an aberrant artery arising from the abdominal aorta and supplying the right basal segment and patent ductus arteriosus(PDA).Moreover the sequestrated lung was not recognized. Based on these findings we diagnosed the patient with anomalous systemic arterial supply to the basal segment of the right lung with PDA. Her pulmonary-to-systemic blood flow ratio was 1.10. Therefore we planned to treat the PDA someday afterwards. Right basal segmentectomy and transection of the aberrant artery by using only autosuturing device were performed. Five months later, three-dimensional computed tomography showed no aneurysm of the cut end of the abnormal vessel.
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Source:
胸部外科 65巻13号, 1184-1187 (2012);
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Pleomorphic carcinoma is rare in the primary lung cancer with a poor prognosis. We reported a resected case of pleomorphic carcinoma of the lung with rapid progression. A 62-year-old male with a tumor shadow in the right lung which had not been noted 9 months before was referred to our hospital. The abnormal shadow was not noted 9 months ago. The tumor located in the right lower lobe and rapidly enlarged from 7.5 cm to 9.5 cm in a month. Right pneumonectomy was necessary, because of the intrapulmonary metastasis in the right upper lobe. Pathological findings showing spindle cells with massive necrosis, were consistent with a diagnosis of pleomorphic carcinoma. Only by 45 days after operation, local recurrence and metastases to the brain, right adrenal gland and small intestine were found, resulting in death at 67 days after operation.
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まい・てくにっく
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Source:
胸部外科 65巻13号, 1112-1113 (2012);
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1枚のシェーマ
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Source:
胸部外科 65巻13号, 1142-1142 (2012);
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胸部外科医の散歩道
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Source:
胸部外科 65巻13号, 1154-1154 (2012);
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画像診断Q&A
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Source:
胸部外科 65巻13号, 1160-1164 (2012);
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書評
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Source:
胸部外科 65巻13号, 1172-1172 (2012);
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