Volume 66,
Issue 10,
2013
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胸部外科の指針
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Source:
胸部外科 66巻10号, 861-869 (2013);
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We carried out a retrospective evaluation of the early and mid-term outcomes of aortic valve replacement (AVR) for aortic stenosis in hemodialysis patients. Between 2004 and 2012, a total of 40 dialysis patients underwent AVR with or without an additional procedure. Hemodialysis was performed routinely the day before and during the operation. At surgery, decalcification was performed using a cavitron ultrasonic surgical aspirator(CUSA) and a high performance mechanical valve was then implanted, with the exception of elderly patients or those in whom use of oral anticoagulation is contraindicated. A mechanical valve was used in 33 patients and a bioprosthetic valve in 7 patients. Hemodialysis was resumed on the 2nd postoperative day in the majority of patients. There was no intra-operative death and in-hospital mortality was 5%, due to sepsis and intestinal ischemia in 2 of the 40 patients. The mean follow-up period was 33 months. There was no structural valve deterioration in patients with the bioprosthetic valve. Of the 8 late deaths, the reason for deaths was cardiac in 4 patients. Overall survival in the 40 patients was 92%, 79%, and 54% at 1, 3, and 5 years, respectively. Our study demonstrated good early and mid-term outcomes for aortic valve replacement in hemodialysis patients. CUSA was useful for patients with a calcified valve and annulus. A bioprosthetic valve was acceptable for use in elderly patients.
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今月の臨床
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Source:
胸部外科 66巻10号, 872-875 (2013);
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Intraoperative aortic dissection is a rare complication of open heart operations. Once dissection has occurred, great caution is required because of high mortality rate. We reported 4 cases of intraoperative aortic dissection. The incident rate was 0.08%, and the most common site of aortic injury was the aortic cannulation site( 3/4 patients). Intraoperative epiaortic echography is effective in diagnosis. All cases underwent graft replacement of the ascending aorta. The postoperative course was uneventful. Both prompt recognition and appropriate surgical management are mondatory to improve operative outcome.
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臨床と研究
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Source:
胸部外科 66巻10号, 876-881 (2013);
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Our modification of Starnes’ procedure reduces right ventricular volume using only“ suture plication” to improve surgical outcomes. However, shunt size in the procedure varies widely between patients. As this may be related to small lung volume, we estimated lung volume in each patient using computed tomography (CT).Since 2007, we have performed Starnes’ procedure in 4 patients. Preoperative cardiothoracic ratio was 89±4.5%. Age and body weight at operation were 4.3±2.6 days and 2.6±0.2 kg, respectively. Anatomic slices 3 mm thick were acquired in transverse planes by CT. Total lung volume was calculated by accumulating those slices. Total lung volume and lung volume/body weight were 97.2±34.1 ml, 36.8±11.5 ml/kg, respectively. In one patient, a 3 mm prosthetic graft was needed to place a clip to regulate blood flow. Another patient required an additional shunt. The patient with the smallest lung volume required treatment with an extracorporeal lung-assistance device. Chest X-rays of neonates with severe Ebstein’s anomaly usually show a“ wall-to-wall” heart. However, lung volume varies widely between patients. Estimation of lung volume using CT is useful. In patients with smaller lung volume, a larger shunt than usual may be required to obtain the necessary pulmonary blood flow.
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今月の話題
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Source:
胸部外科 66巻10号, 882-885 (2013);
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We report a rare surgical case of synchronous multiple primary lung cancers with synchronous multiple colon cancers. A 74-year-old woman was incidentally pointed out abnormal chest shadows. Chest computed tomography revealed 2 nodules in the right upper and middle lobe. Transbronchilal lung biopsy (TBLB) was done, and the tumor in the middle lobe was diagnosed as adenocarcinoma. In addition, positron emission tomography pointed out colon cancer. Colon fiber revealed multiple colon polyps and colon cancers. Immunostaining with thyroid transcription factor (TTF)-1 and Napsin-A for TBLB specimen was done to distinguish their association. With the diagnosis as primary lung cancer, we performed right upper and middle lobectomy with lymph node dissection. These tumors were pathologically diagnosed as synchronous multiple primary lung cancers with adenocarcinoma and squamous cell carcinoma. Several months later, colon regions were resected through colonoscopic endometric mucosal resection and left hemicolectomy.
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Source:
胸部外科 66巻10号, 886-889 (2013);
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A 72-year-old man had underwent left lower lobectomy for squamous cell carcinoma in our hospital in 2008. Postoperative stage was ⅠA (T1N0M0). In 2010, follow-up chest computed tomography (CT) images showed similar cavitary nodules in segments 2 and 8 of the right lung with positive uptake on fluorodeoxyglucose-positron emission tomography (FDG-PET) images. Physical examination, blood tests, and levels of serum tumor markers showed no abnormality. Transbronchial lung biopsy revealed the absence of malignant cells. Segment 8 of the right lower lobe with the nodule was partially resected, and pathological examination demonstrated lung abscess. He was discharged but was hospitalized in another hospital for purpuric rash, fever, and arthralgia. Microscopic albuminuria was noted, and renal biopsy revealed nephritis with immunoglobulin A( IgA)deposition. He was made a diagnosis of Henoch-Schönlein purpura. Oral steroid therapy( prednisolone 60 mg/d) was initiated, resulting in the improvement of symptoms and disapearance of the cavitary nodule in the right lung segment 2.
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Source:
胸部外科 66巻10号, 890-893 (2013);
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We report a case of lung cancer treated with pirfenidone as preoperative therapy before subsequent successful surgical resection. A 76-year-old man was admitted to our hospital because of abnormal shadows and diffuse reticular shadow in bilateral lung on chest computed tomography(CT). CT-guided percutaneous lung biopsy confirmed suquamous cell carcinoma for both lung. Pulmonary reticular shadow was diagnosed as idiopathic pulmonary fibrosis (IPF) clinically and the pirfenidone was administered 600 mg daily and increased by 600 mg for every week until 1,800 mg/day to control IPF. After 3 weeks pirfenidone therapy, Krebs von den Lungen( KL)-6, pulmonary surfactant( SP)-D and lactate dehydrogenase (LDH) decreased, and the patient underwent wedge resection. His postoperative course was uneventful.
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手術の工夫
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Source:
胸部外科 66巻10号, 894-897 (2013);
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An 80-year-old woman was referred to our institution because of acute heart failure due to moderate mitral stenosis and severe regurgitation. After medical treatment of heart failure, she underwent mitral valve surgery. Intraoperatively severe calcification of the posterior mitral annulus was revealed. We excised only the anterior mitral leaflet and preserved the posterior mitral leaflet to prevent a fatal complication such as left ventricular rupture, injury of the coronary artery or embolism. Partial resection of the calcified annulus was performed using Ultrasonic Surgical System (SonoSurg), after 2-0 polyester mattress sutures were placed through the anterior and posterior annuli from the left ventricle to the left atrium. Then, mitral valve replacement was performed using a St. Jude Medical mechanical heart valve at the supra-annular position. The postoperative course was uneventful. We concluded that partial resection of a severely calcified posterior mitral annulus by the ultrasonic device was a safe and simple procedure.
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Source:
胸部外科 66巻10号, 898-901 (2013);
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We describe a baby girl with isolate absence of the right pulmonary artery. She had tachypnea just after birth. Several examinations showed absence of the right pulmonary artery and an aortopulmonary collateral artery. After follow-up, cardiac catheterization was performed the age of 14 months. It showed mild pulmonary artery hypertension. The posterior wall of right pulmonary artery was reconstructed with U-shaped in situ pulmonary artery flap and the anterior wall was reconstructed with autologous pericardium patch. Enhanced computed tomography was performed on postoperative day 9 showed occlusion of the right pulmonary artery by a thrombus. Emergency catheterization and thrombolytic therapy was performed with no success. Then, we successfully performed thrombectomy by open surgery. Cardiac catheterization performed at 6 months after the operation showed patency of the right pulmonary artery and improvement of pulmonary artery hypertension.
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臨床経験
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Source:
胸部外科 66巻10号, 903-906 (2013);
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A 27-year-old woman with Turner’s syndrome who underwent successful endovascular treatment for coarctation of the aorta is presented. She was admitted to our hospital complaining of upper extremity hypertension. Computed tomography revealed discrete stenosis of the proximal descending aorta and developed collateral circulation. After endovascular repair with a balloon expandable stent, her transcoarctation gradient fell from 44 mmHg preoperatively to less than 10 mmHg. She was discharged with no complications on the 7th postoperative day. Coarctation of the aorta in an adult patient could be safely and effectively managed by endovascular treatment.
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Source:
胸部外科 66巻10号, 907-910 (2013);
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Metastatic cardiac tumors are commonly detected during autopsy. However, they are seldom diagnosed during life, and surgical resection is rarely indicated. Among the malignant tumors, colon cancer rarely metastasizes to the heart. We report a case of a 70-year-old woman with sigmoid colon cancer, which metastasized to her heart and caused obstruction of the right ventricular outflow tract. The tumor had already metastasized to the liver, lungs, periaortic lymph nodes, and peritoneum. Cardiopulmonary bypass surgery was performed to excise the right ventricular metastatic tumor and to reconstruct the tricuspid valve. Histological analysis of the specimen confirmed a metastatic adenocarcinoma. Although this surgery was performed as palliative cancer therapy, the patient’s symptoms were satisfactorily improved. Follow-up echocardiography 2 months after her cardiac surgery showed no space-occupying mass in the right ventricle.
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Source:
胸部外科 66巻10号, 911-914 (2013);
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A 68-year-old woman was referred to our hospital due to a left chest abnormal shadow on chest film. She had a history of occupational exposure to organic solvent for about 30 years until 10 years ago. Computed tomography (CT) scan demonstrated a nodular shadow 12 mm in diameter in the left lower lobe. As a lung cancer was suspected, partial resection of the lobe including the small lesion was performed. Since mucosa-associated lymphoid tissue(MALT) lymphoma was diagnosed by intraoperative pathological examination, we finished the operation without any more lung resection. The diagnosis was finally confirmed by histological finding of small lymphoid cell proliferation and positive staining for CD20. Chronic inflammation, such as Helicobacter pylori infection, is considered to be a cause of MALT lymphoma. We speculate that the long term exposure to organic solvent may develop the disease by continuous chemical stimulation to bronchus.
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Source:
胸部外科 66巻10号, 915-918 (2013);
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We carried out right upper lobectomy and mediastinal node dissection for a 67-year-old man with lung adenocaricinoma in the right upper lobe. Intraoperatively, we found the middle lobe vein, V2, and V3 in front of the pulmonary hilum, and did not found a part of the right apical pulmonary vein. We found a part of the right apical pulmonary vein placed between the right main pulmonary artery and the right upper lobe bronchus, after cutting the pulmonary artery branches to the right upper lobe. We should keep on mind the possibility of anomalous course of pulmonary vein when pulmonary surgery is planned. And, if this abnormality is doubted with the preoperative chest computed tomogrphy (CT) scan, threedimensional CT( 3D-CT) scan of the pulmonary vein is useful.
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症例
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Source:
胸部外科 66巻10号, 930-933 (2013);
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A 34-year-old man experienced lower limb ischemia due to tumor emboli as an initial symptom. Histopathologic examination of the embolic material revealed undifferentiated sarcoma. By echocardiography the original tumor was arising from the posterior mitral leaflet, and therefore, excision of the mitral valve resulted in complete resection of the sarcoma. Mitral valve replacement was performed, and his postoperative course was uneventful. He did not receive postoperative adjuvant therapy. The patient has been undergoing positron emission tomography and electrocardiography on an outpatient basis to check for signs of recurrence. However, no signs of recurrence have been detected for 7 years postoperatively, and the patient leads an active life.
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Source:
胸部外科 66巻10号, 934-937 (2013);
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The patient was a 45-year-old female, who was emergently hospitalized with presyncope. Brain magnetic resonance imaging (MRI) confirmed an infarct in the left middle cerebral artery area. Echocardiography revealed mobile vegetations on the mitral valve and aortic valve, and the patient was diagnosed as having infective endocarditis. She was treated conservatively by appropriate antibiotic therapy. Four days after hospitalization, the patient developed brain hemorrhage due to ruptured mycotic cerebral aneurysm, and craniotomy for removal of the hematoma and brain aneurysm clipping were performed on the same day. As 3-dimensional computed tomography (3D-CT) obtained 2 weeks after the surgery suggested the existence of other brain aneurysms, it was determined that continued conservative management of the infection might not be feasible, and mitral valve and aortic valve replacements were performed 3 weeks after the craniotomy. The postoperative clinical course was satisfactory, without the complications of bleeding, aggravation of the cranial nerve disorders or recurrence of the infection. Ruptured mycotic cerebral aneurysms are usually associated with a poor prognosis. There are no specific guidelines for the treatment of infective endocarditis with brain complications like in this case, and it is important to select therapies tailored to individual cases.
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Source:
胸部外科 66巻10号, 938-940 (2013);
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Descending necrotizing mediastinitis( DNM) is often a lethal condition resulting from odontogenic or cervical infection, with a previously reported mortality rate of 25 to 40%, which is known to accompany occasional pericardial effusion. Here, we report a case of diffuse DNM with cardiac tamponade.
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Source:
胸部外科 66巻10号, 941-943 (2013);
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A 70-year-old man was followed up at the surgery department of our hospital after colon polypectomy. It was pointed out that the level of carcinoembryonic antigen(CEA) was high at blood test. Chest computed tomography (CT) showed small nodule close to the pulmonary vein in the right lower lobe (S6-S10), 15 mm in size, in September 2011. Fluorodeoxyglucose-positron emission tomography( FDG-PET)/CT scanning revealed a positive reaction in the right lower lobe lesion. He was introduced to our department. The video-assisted thoracoscopic surgery (VATS) was performed to establish diagnosis and treat. Histopathological examination showed no malignancy and chronic eosinophilic pneumonia(CEP).In a case of the solitary lung nodule patient with the past history of asthma or the atopic disease, CEP should be included in the differential diagnosis.
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連載/臨床データベースを用いた研究―現状と方法⑥
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Source:
胸部外科 66巻10号, 919-924 (2013);
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Measurement and feedback of clinical performance is one of the important activities in clinical database. In addition, clinical database is used for developing medical guidelines, research for public policy and clinical research, and also various kinds of information can be provided to the public. On the other hand, risk adjustment for data analysis is a key issue in the clinical database. From these viewpoints, this article described the activities for quality improvement, examples of research, and planning of clinical research using the clinical database.
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まい・てくにっく
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Source:
胸部外科 66巻10号, 870-871 (2013);
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1枚のシェーマ
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Source:
胸部外科 66巻10号, 902-902 (2013);
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胸部外科医の散歩道
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Source:
胸部外科 66巻10号, 925-925 (2013);
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画像診断Q&A
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Source:
胸部外科 66巻10号, 926-929 (2013);
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