胸部外科

Introduction of spinal surgery into the operation of lung cancer has made extensive surgical treatment feasible with acceptable long-term survival. We report our experience on total en bloc total spondylectomy for lung cancer invading the spine. A 60-year-old man was diagnosed with lung adenocarcinoma of the apicodorsal segment of the left lobe with invasion of the 2nd and 3rd thoracic vertebral bodies. After induction chemoradiotherapy, we performed en bloc resection through a posterolateral thoracotomy in the right decubitus position and a posterior median approach in the prone position. The thoracic manipulation was done earlier, making it useful for the dissection of the prevertebral plane from the posterior mediastinum at the upper thoracic level in addition to confirmation of non-N2 disease. Vertebral stabilization was achieved with rod fixation and placement of a titanium mesh cage between the remaining vertebral bodies.

Background：The open stent grafting, in other words “frozen elephant trunk （FET）” technique has been played an important role in surgical treatment of extensive thoracic aortic pathologies. J Graft Open Stent Graft （JOSG） was a new Japan-made commercially available product. We have recently introduced this attractive device as an alternative to self-made open stent graft. Patients：Twenty consecutive patients underwent aortic arch replacement using the JOSG as a FET in our institution. A JOSG was implanted：atherosclerotic thoracic aortic aneurysm （n＝10）， acute type A aortic dissection（ n＝6）， chronic type B dissection（ n＝4）. Results：There was no operative death, but 1 patient died of multiple organ failure 5 weeks after the operation. Spinal cord injury was observed in 1 patient. Although JOSG implantation was completed in all patients, we experienced 2 cases of technical device failure during operation. After distal anastomosis with the insertion of JOSG to the downstream aorta, antegrade perfusion of extracorporeal circulation became difficult due to JOSG obstruction. Severe kinking of JOSG might occurred because of the tortuous distal arch to descending aorta and the excellent flexing properties of the JOSG. In patients with aortic dissection presenting narrow true lumen, subsequent endovascular stent graft placement was required because of inadequate obliteration of the false lumen. Conclusions：Thoracic aortic surgery using JOSG was introduced and performed with acceptable morbidity and mortality. JOSG was expected to contribute to the surgical treatment of thoracic aortic diseases, but a few serious complications of JOSG related to its structural property should be kept in mind for the safety of the procedure.

We retrospectively assessed the effectiveness and the safety of thoracic paravertebral block（PVB） in patients ineligible for epidural block （EP）. Eleven PVB patients and 33 EP patients were enrolled. Postoperative pain was evaluated using a numerical rating scale （NRS）. The mean NRS ± standard deviation at rest 24 and 48 hours after surgery were 1.36 ± 1.63 and 0.55 ± 1.03 in the PVB group and 1.07 ± 1.47 and 1.38 ± 1.31 in the EP group, respectively. There were no statistically significant differences in the NRS scores. Approximately 10％ of the EP patients had complications such as hypotension, nausea and vomiting, or urinary retention. On the other hand, there were no adverse events in the PVB group. PVB can provide pain relief comparable to EP with a better side-effect profile. There were no technical complications associated with PVB. Thoracic PVB is an effective and safe method of postoperative analgesia for patients undergoing thoracic surgery with ineligibilities for EP.

A 77-year-old man with a history of stent implantation in the right common iliac artery（CIA） and the left external iliac artery（EIA） was admitted to our hospital for a rapid growth of an aneurysm（ max 53 mm） at Th11 level of the descending aorta. Although thoracic endovascular aortic repair （TEVAR） was required, there were many problems about access rout. The infrarenal abdominal aorta and the left EIA were severely calcified, and the lumens of the right CIA stent（5.3 mm） and the left EIA stent（ 4.3 mm） were small in size. Besides, the left CIA was short（13 mm）. Therefore, TEVAR was performed by retrograde approach from the left internal iliac artery（ IIA） with a tube graft conduit in the hybrid operation room. IIA is a useful option for an access rout in endovascular aortic repair.

A strategy of indicating lung excision for high risk patients is discussed based on reviewing of treatments for clinical stage I lung cancer. According to clinical studies of lung excision or stereotactic body radiation therapy both results may be similar, while a multicenter randomized prospective study is on-going. Since the result of lung excision may be revealed to depend on tumor size, tumor location in the lung, distance from surgical margin to tumor, tumor size-margin distance ratio and margin cytology results, a prospective study is recommended, which will be able to assessed clinical implications of such factors to extract patients having good prognoses.

Thrombosis around intravenous catheters are often found in daily practice, and their treatment must be considered if they are mobile or large. However, in such giant thrombosis cases as this one, it is considered that thrombolytic therapy is ineffective and that immediate surgical resection is the best choice of treatment. The patient had a very uniquely-shaped right atrial thrombus.

Case 1：A 62-year-old man underwent right S9＋10 segmentectomy for non-small cell lung cancer. Three years later, pleural thickening appeared in the apex, and gradually developed cystic change. Case 2：A 64-year-old man underwent left upper lobectomy for non-small cell lung cancer. One year after surgery, chest computed tomography （CT） showed cysts in the apex of the lower lobe. The cysts expanded slowly with consolidation. Both cases were diagnosed as chronic progressive pulmonary aspergillosis. Although anti-fungal drugs were administered in both cases, case 1 died of the disease. Chronic progressive pulmonary aspergillosis is a rare late postoperative complication；when CT shows progressive cysts with consolidation in the apex area of the residual lung, frequent check-ups are needed.