胸部外科
Volume 66, Issue 2, 2013
Volumes & issues:
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胸部外科の指針
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肺癌手術例における低用量未分画heparin の術後肺塞栓症予防効果と安全性の長期成績
66巻2号(2013);View Description Hide DescriptionWe evaluated the efficacy and safety of the administration of low-dose unfractionated heparin(LDUH)for the prevention of pulmonary thromboembolism after lung cancer surgery. We operated on 206 patients with primary lung cancer for 8 years;128 males and 78 females, mean age:69.9±8.8 years. All patients were administrated LDUH 5,000 units every 12 hours from the operation day until the day when the patient could walk around the floor. No patients suffered from clinical pulmonary thromboembolism in this period. The duration of treatment was 4.6±2.6 days and the chest tube duration was 5.4±3.0 days. We experienced post-operative intra-thoracic bleeding in 2 patients during the previous 4 years. Based on this experience, we introduced new eligibility criteria;we discontinued LDUH administration on the operation day if diffuse adhesion in the thoracic cavity was observed at operation or intraoperative blood loss was over 500 ml. The dose of LDUH was decreased to 2,500 unit every 12 hours if the postoperative bleeding was over 400 ml on the operation day or the patient’s body weight was less than 40 kg. After introduction of the new criteria, no severe bleeding complications occurred during the latter 4 years.
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今月の臨床
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再発性人工弁感染,大動脈弁輪膿瘍の播種性血管内凝固症候群に対するthrombomodulin-αの早期導入有効例
66巻2号(2013);View Description Hide DescriptionProsthetic valve endocarditis(PVE)occasionally evokes sepsis and disseminated intravascular coagulation(DIC). A 46-year-old man developed relapsing active PVE with an annular abscess and suffered from exacerbating sepsis and DIC. Despite the administration of antibiotics, his DIC score increased. Anti-DIC treatment with recombinant thrombomodulin (rTM) was initiated, and his DIC was remarkably resolved. Accordingly, the abscess cavity was closed by using a homograft anterior mitral leaflet, and the aortic root was replaced with the homograft. He is doing well without an evidence of recurrent endocarditis 18 months after the operation. rTM is a new and promising drug for the treatment of DIC with infective endocarditis.
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臨床と研究
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MDCT 三次元構築像の体表面投影による低侵襲心臓外科手術支援
66巻2号(2013);View Description Hide DescriptionPort-access minimally invasive cardiac surgery (MICS) is complicated by limited skin incision and surgical field. In order to optimize the set-up and port placement in this surgery, we have employed image overlay technique prior to operation consisted of three-dimentional computed tomography (3DCT)image projection on the patient surface. With the aid of this technique, we successfully performed port-access MICS in 12 patients and mitral valve replacement in 1 patient with severe mediastinal displacement after previous pneumonectomy. Image overlay projection could allow surgeons to view underlying anatomical structures virtually and obtain a good operative field. Our proposed technique would be expected to make port-access MICS easier and probably safer in this particular circumstance.
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今月の話題
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内視鏡を用いて経僧帽弁的に左室内血栓摘出を行った左室心筋緻密化障害
66巻2号(2013);View Description Hide DescriptionWe report a case of isolated left ventricular non-compaction(LVNC) associated with poor left ventricular function, multiple cerebral infarctions, and a mobile and pedunculated thrombus in the left ventricular apex. LVNC is a rare congenital cardiomyopathy resulting from an arrest in normal endomyocardialembryogenesis. The thrombus and some other small thrombi in the left ventricle were successfully removed through the mitral valve using an endoscope without making a left ventricular incision to preserve cardiac function. Mitral annuloplasty, the maze procedure, and left atrial thrombectomy were alsoperformed. The patient’s postoperative course was uneventful. By using an endoscope, details of the left ventricular cavity could be observed, and left ventricular function could be preserved by avoiding ventriculotomy. -
ステントグラフト内挿術後に左肺上葉切除術を行った大動脈浸潤肺癌
66巻2号(2013);View Description Hide DescriptionA 52-year-old man with fever and dyspnea was admitted to our hospital. Chest computed tomography showed a mass measuring 3.5×3.0 cm in the S1+2 segment of the left lung with involvement of the aorta. Although cytological examination using bronchofiberscopy did not show any malignancy, we suspected the mass to be T4N0M0 lung cancer. The tumor was diagnosed as having invaded the aorta using intravascular ultrasound. First, an endovascular graft was inserted, and then, a left upper lobectomy with resection of the infiltrated aortic wall was performed without cardiopulmonary bypass. The patient had an uneventful recovery without any complications. Pathological examination revealed the tumor to be a large-cell carcinoma. We think that an aortic endograft can be useful for resection of an infiltrated aortic wall, although further studies are necessary.
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手術の工夫
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遠位弓部大動脈瘤に対するステントグラフト内挿術時の脳梗塞予防―左鎖骨下動脈バルーンテクニック
66巻2号(2013);View Description Hide DescriptionThoracic endovascular aneurysm repair(TEVAR) has been applied more and more frequently to an atherosclerotic distal aortic arch aneurysm. Even if the procedure is successful, extensive cerebral infarction might occur, especially in the left vertebral artery area. We therefore devised a new method to prevent embolic events using a thrombectomy catheter with an end hole, which was placed at the origin of the letf subclavian artery via the radial artery. This simple left subclavian artery balloon technique not only prevents cerebral embolism in the left vertebral artery system, but also provides a position marker under X-ray, and enables tight compaction of the embolization coils. -
横隔膜・肋間筋を温存した胸腹部大動脈瘤手術
66巻2号(2013);View Description Hide DescriptionIn thoracoabdominal aortic aneurysm (TAAA) repair, postoperative respiratory complication is a major problem. TAAA repair was performed in a 75-year-old man. The computed tomography showed a TAAA (Crawford type Ⅳ) with shaggy descending thoracic aorta. Stomach and small intestine were compressed by the TAAA with resultant appetite loss. And reduced respiratory function was observed. In such a case thoracotomy is usually required for operation. However, we applied the extra pleural dissection without thoracotomy, and the diaphragm and intercostal muscles were preserved. Using the selective abdominal organ perfusion, graft replacement was performed between iliac arteries and descending aorta. The postoperative course was uneventful, and respiratory function was preserved.
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臨床経験
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右頸動脈血流不全が大動脈修復後も改善しなかったStanford A 型急性大動脈解離
66巻2号(2013);View Description Hide DescriptionA 61-year-old man suddenly developed transient left hemiplegia and consciousness disturbance. Computed tomography showed acute Stanford type A aortic dissection. Dissection affected the entire right common carotid artery, and its false lumen extremely compressed the true lumen. The right common carotid artery, along with the right femoral and the left axillary arteries, was used as an inflow of cardiopulmonary bypass during emergency surgery. The ascending aorta that included a large intimal tear was replaced. However, systemic reperfusion either through the femoral artery or through a side branch of vascular prosthesis failed to restore the right cerebral blood flow due to persistent true lumenobstruction by the expanded false lumen in the innominate artery. Therefore, ascending aorta-right carotid artery bypass using that side branch was performed immediately. Though temporary cerebral malperfusion could cause dismal outcome, direct carotid artery cannulation played a key role in this successfully-treated patient. -
胸部食道癌術後乳び胸の治療法選択
66巻2号(2013);View Description Hide DescriptionWe performed 250 chest esophagus cancer operation from 1998 through 2008 in our department. It was 8 cases (3.2%) that post esophagectomy chylothorax developed. The surgical therapy performed thoracotomy in 2 patients, and 2 patients performed thoracoscopic surgery. We used an extended image with the thoracoscope for all surgery cases. Therefore, we were able to conduct identification of chyle leakage department easily. In the course after the treatment, we divided cases into a surgery treatment group and the non-surgery treatment group and compared a period until oral intake initiation and thepostoperative hospitalization. The oral intake initiation was an average of 16.7 days in the surgery treatment group. Also, the hospitalization after surgery was an average of 44.3 days. In contrast, the oral intake initiation was an average of 35 days in the non-surgery treatment group. Also, the hospitalization after surgery was an average of 56 days. Oral intake initiation and a discharge were possible earlier in a surgery treatment group. -
肺癌術後腎梗塞と急性下肢動脈閉塞の合併例
66巻2号(2013);View Description Hide DescriptionThe patient was 68-year-old who underwent left upper lobectomy and lymph node dissection. On the 4th postoperative day, he developed vomiting and lumbar pain. On 5th postoperative day, he complained of pain, sensory paralysis and cold sensation of the right lower extremity. Computed tomography(CT)examination revealed left renal infarction and acute arterial obstruction of the right common iliac artery. Emergency thrombectomy of the right lower extremity was performed. Postoperatively, he received anticoagulant therapy and was able to leave the hospital on the 20th postoperative day. Attention should be paid to the infarction of abdominal organs when developing abdominal symptoms after lung cancer surgery in elderly patients. -
肺類上皮血管内皮腫
66巻2号(2013);View Description Hide DescriptionA 62-year-old asymptomatic woman was referred to the National Cancer Center Hospital in Japan because of an abnormal shadow on an annual checkup chest X-ray. Chest computed tomography(CT)showed a well-demarcated nodular lesion of 3 cm in diameter in the right lower lobe. Since the nodule was located at the right pulmonary hilum, she underwent a right lower lobectomy. Histologically, the tumor was composed of solid nests or anastomosing strands of cells that were embedded in a hyalinized, focally myxoid stroma. Some of the tumor cells showed a striking feature of the presence of intracytoplasmiclumina that were visualized as clear spaces or vacuoles. These lumina were negative for alcian blue and periodic Schiff, and contained erythrocytes. Immunohistochemically, the tumor cells were stained for CD31 and FLI1. The tumor was diagnosed as a pulmonary epithelioid hemangioendothelioma.Pulmonary epithelioid hemangioendothelioma is a relatively rare entity.
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症例
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2 回の心臓血管外科手術を必要としたホモ型家族性高コレステロール血症の1 例
66巻2号(2013);View Description Hide DescriptionA 46-year-old woman with homozygous familial hypercholesterolemia was referred due to aortic regurgitation. The patient was introduced selective low density lipoprotein cholesterol(LDL)apheresis 20 years ago. Echocardiogram revealed severe aortic regurgitation, and computed tomography revealed thoracoabdominal aortic aneurysm. We considered 2 staged operations were necessitated. Firstly, aortic valve replacement was performed. Emergent coronary artery bypass grafting was also done because intraoperative myocardial ischemia was strongly suspected from left ventricular hypokinesis. One year later, replacement of thoracoabdominal aorta was performed. Post-operative course was uneventful and the patient was discharged at post-operative day 21. The patients with homozygous familial hypercholesterolemia must be strictly followed up because systemic atherosclerosis frequently exacerbates despite selective LDL apheresis. -
急性心筋梗塞後重複心破裂(心室中隔穿孔+blowout 型左室自由壁破裂)の1 例
66巻2号(2013);View Description Hide DescriptionWe report a case of successful surgical repair of combined ventricular septal perforation and blowout free wall cardiac rupture(double rupture) after acute myocardial infarction. The patient was a 59-yearold man, who suffered an extensive acute anterior myocardial infarction. Although emergent coronary angiogram and coronary intervention was performed, he collapsed in a state of electro-mechanical dissociation in the catheterization laboratory. He was resuscitated by percutaneous cardiopulmonary support system (PCPS) and transferred to the operation theater. Infarction exclusion using bovine pericardial patch was performed. He was weaned from PCPS on day 5 after surgery and discharged hospital on day 65 with good health. -
大動脈弁置換術後に完全房室ブロックで吻合部仮性瘤を発見した1 例
66巻2号(2013);View Description Hide DescriptionAortic pseudoaneurysm is a late complication after cardiac surgery. The patient was a 63-year-old female who had undergone aortic valve replacement 3 years before. She complained of syncope and underwent pacemaker implantation for complete atrioventricular block. Aortic root pseudoaneurysms were accidentally detected by computed tomography, and 1 of them was 50 mm in size. She underwent aortic root replacement with a modified Bentall technique. Although there was no definite infection or inflammation, careful follow-up was considered to be mandatory. -
無冠尖瘤の穿孔を認めた大動脈弁閉鎖不全症の1 例
66巻2号(2013);View Description Hide DescriptionThis case report describes a 77-year-old man who developed infective endocarditis resulting in perforated aneurysm of the non-coronary cusp with aortic regurgitation. Diagnosis was made by transesophageal echocardiogram and successful surgical valve replacement was performed. -
細気管支肺胞上皮癌部分切除後の切除断端近傍に発生した第2 癌の1 例
66巻2号(2013);View Description Hide Description77-year-old man was treated by wedge resection for bronchioloalveolar carcinoma (BAC) of right upper lobe 6 years before. Follow up computed tomography (CT) performed 5 years later revealed partial thickening of the resected line of the initial surgery which was diagnosed as adenocarcinoma with bronchoscopic cytology. Thoracoscopic right upper lobectomy and nodal dissection was performed. Histological diagnosis was papillary adenocarcinoma, which was thought to be a 2nd primary lung cancer. -
外科療法後rituximab 治療を行った肺原発粘膜関連リンパ組織(MALT)リンパ腫の1 例
66巻2号(2013);View Description Hide DescriptionWe report a case of mucosa-associated lymphoid tissue (MALT) lymphoma of the lung treated by surgery and rituximab. A 47-year-old man was referred to our hospital because of the lesion in the right middle lobe, which had enlarged gradually. Chest computed tomography(CT) scanning showed an infiltrative shadow of the right middle lobe. He underwent right middle lobectomy for the MALT lymphoma whose diagnosis and treatment. The tumor was pathologically diagnosed as CD20 immunostaining was positive and the adjuvant treatment by rituximab was performed. -
血胸手術を契機に診断された血管型Ehlers-Danlos 症候群の1 例
66巻2号(2013);View Description Hide DescriptionVascular-type Ehlers-Danlos syndrome(vEDS) is a rare autosomal dominant inherited disorder of the connective tissue, which often causes arterial ruptures and surgical complications. We report the case of a vEDS patient who was incidentally diagnosed at surgical treatment for hemothorax. A 64-year-old woman with a past history of hysterectomy due to excessive bleeding during childbirth visited our hospital complaining of chest pain. Chest computed tomography revealed right pleural effusion suspected of hemothorax and a high density area behind the right anterior chest wall. Emergency thoracoscopy revealed bloody spots throughout the mediastinal pleura, suggestive of bleeding from the right internal thoracic artery. During thoracoscopy, easy bruising of the tissue by surgical manipulation was noted which led us to suspect connective tissue disease. A biochemical analysis by cultured dermal fibroblasts and molecular biological examination established the diagnosis of vEDS.
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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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