胸部外科

Purpose：To compare the effectiveness of continuous distal perfusion（ CDP） with that of intermittent distal perfusion（ IDP） during frozen elephant trunk（ FET） procedures. Methods：There were 54 patients in the CDP group and 15 patients in the IDP group. There were no significant differences in preoperative characteristics between the two groups, but dissection was more common in the IDP group than in the CDP group, and the maximum aneurysmal diameter was larger in the CDP group than in the IDP group. Results：Emergency surgery was significantly more common in the IDP group than in the CDP group. Operating time, cardiopulmonary bypass time, lower body arrest time, and aortic cross-clamp time were significantly longer in the IDP group. Postoperative paraparesis occurred in one case in each group, and temporary paraparesis occurred in two cases in the CDP group, with no significant differences, including in mechanical ventilation time. There were two in-hospital deaths, one due to respiratory failure and one due to ischemic colitis, in the CDP group and one due to multiple organ failure in the IDP group. Postoperative liver and renal functions did not differ significantly between the two groups. Conclusion：IDP has proven to be almost as effective as CDP during FET for preventing spinal cord ischemia and maintaining respiratory, liver, and renal functions.

Bacille Calmette-Guérin（ BCG） intravesical therapy is an effective and safe treatment for bladder cancer；however, mycotic aneurysms have been reported as a rare complication. Case 1：A 64-year-old man with a history of BCG intravesical therapy underwent emergent thoracic endovascular aortic repair （TEVAR） for a ruptured thoracic aortic aneurysm （TAA）. He was diagnosed with BCG infection by hemosputum specimen culture five months later；then, antituberculous therapy was initiated. However, his follow-up computed tomography scan revealed stent-graft infection and new aneurysm formation. Therefore, we performed a repeated TEVAR with abdominal 4-vessel debranching. There was no recurrence of infection for six years while continuing postoperative antituberculous therapy. Case 2：A 72-year-old man who had undergone BCG intravesical therapy underwent TEVAR for a rapidly enlarging mycotic TAA. He received anti-tuberculous therapy for one year with no recurrent infection for one year. TEVAR may be an effective alternative to the open surgical procedure；however, multidisciplinary treatment including anti-tuberculous therapy and careful long-term follow up are required.

On October 1, 2021, the Clinical Engineer Law was revised and expanded the task of clinical engineers （CEs）. After that, they can hold and operate a endoscope in endoscopic surgery. On June 9, 2022, our hospital asked CEs to directly participate in thoracoscopic pleural biopsy as scopist（ scope operator） for the first time, and since then, a total of 54 thoracoscopic surgery cases were performed by CEs as scopist over the course of one year. In the CE-supported lung surgery of lobectomy and segmentectomy cases, there was a trend toward an increase in operating time of about 15 minutes, although there was no significant difference in operating time compared with conventional surgery. Other than that, however, there were no particular problems, and we expect that further CE education will provide a favorable surgical environment.

Coronary artery fistula is a rare abnormality in the communication between a coronary artery and any of the cardiac chambers or major vessels. At present, there is no standard surgical treatment and the most appropriate method is selected on a case-by-case basis. We report one case of coronary artery fistulae in which pulmonary artery transection was required around the left main trunk （LMT）. A 62-year-old man who had coronary artery fistulae with an aneurysm which increased from 12 mm to 16 mm in a two-year span. The fistula was located adjacent to the LMT. A complete aneurysm excision under cardiopulmonary bypass was performed, which required pulmonary artery transection. No postoperative complications occurred. Postoperative coronary computed tomography scan showed intact coronary arteries and complete aneurysm removal.

Blow-out type left ventricular free wall rupture is a serious complication of acute myocardial infarction, that carries high hospital mortality rates and poor surgical outcome. We report the case of an 88-year-old woman who developed cardiac tamponade following percutaneous coronary angioplasty for acute myocardial infarction. She was diagnosed with left ventricular free wall rupture, and rupture type was proved to be blow out after median sternotomy. To address this critical condition, we opted for the sutureless technique for its minimally invasive nature and ability to preserve left ventricular function. The patient was discharged from the hospital without any complications 22 days after surgery. Considering favorable, encouraging outcomes of this case, sutureless technique could be regarded as a viable option for blow-out type left ventricular free wall rupture.

Surgical resection of the infected lung with curative intent is the treatment of choice for lung abscesses that are difficult to control with medical treatment alone. However, lung resection is considered difficult in some cases. Herein, we report two cases of destroyed lungs with severe symptoms, for which palliative cavernostomy was performed instead of infected lung resection. Case 1 was a 45-year-old man who had granulomatosis with polyangiitis in both lungs. Steroid pulse and immunosuppression therapies were repeated, resulting in a huge, destroyed lung on the right side with chronic necrotizing bilateral aspergillosis, causing severe symptoms. Considering the bilateral spread and extension of the cavity lesions, cavernostomy was performed for the destroyed right lung. Case 2 was a 73-year-old woman who had undergone a left lower lobectomy for a metastatic lung tumor and developed a destroyed lung with severe symptoms in the residual left upper lobe caused by a non-tuberculous mycobacterial infection. Since a completion pneumonectomy with curative intent was considered too invasive for her poor general condition, cavernostomy was performed for the destroyed lung. Palliative operations significantly relieved the severe symptoms and improved the general conditions of these patients, enabling outpatient follow up.