胸部外科

Purpose：Postoperative atrial fibrillation （POAF） after open heart surgery is common complication. POAF is reported to prolong hospital stay and increase long-term mortality, therefore prevention of POAF is important. It is widely known that beta blocker decrease POAF, and we had used oral beta blocker after open heart surgery. We examined the effect of intraoperative and postoperative administration of intravenous beta blocker（ landiolol） for POAF. Method：We evaluated 291 consecutive patients who underwent open heart surgery from November 2016 to November 2018. Those who underwent open heart surgery after November 2017 were 145, and 100 of the patients（ group A） had intraoperative and postoperative landiolol administration. Those who underwent open heart surgery before November 2017 were 146, and 100 of the patients （group B） did not have landiolol administration. The primary endpoint was incidence of POAF within 7 days after surgery. Result：There was no significant difference in preoperative character between the groups, other than the ratio of males to females（ group A：54 males, 46 females；group B：68 males, 32 females；p＜0.05）. The incidences of POAF were 20％ and 36％ in group A and group B, respectively（ p＜0.05）. Conclusion：Intraoperative and postoperative administration of landiolol is effective for preventing POAF after open heart surgery.

We report a case of pseudoaneurysms at the anastomotic sites after prosthetic graft replacement for Immunogloblin G4 （IgG4）-related thoracic aortic aneurysm. A 69-year-old male patient underwent ascending and aortic arch replacement and open stent graft insertion. Five months after the surgery, pseudoaneurysms at the anastomosis to the brachiocephalic artery and to the left common carotid artery developed, and urgency surgery was performed. The right common carotid artery, the right subclavian artery, and the left common carotid artery were individually reconstructed with grafts, and the anastomoses were wrapped with grafts. In IgG4-related aneurysms, complete resection of the diseased tissue and reinforcement of the anastomosis, such as anastomotic wrapping, are important to prevent anastomotic site failure. While serum IgG4 had normalized after the first surgery, C-reactive protein （CRP） remained elevated until the reoperation. Thus, CRP is considered one of the biomarkers for disease activity in IgG4-related vascular disease.

We report a case of a solitary fibrous tumor with repeated lung metastases after resection of the primary tumor. The patient was a 58-year-old man who had a left upper lobe lung tumor resected in 2018. The tumor was a solitary fibrous tumor arising from the visceral pleura. During the subsequent follow-up, the tumor repeatedly metastasized into the lung, and a total of three surgeries were performed. From the specimen at third surgery, the possibility of the enucleation of the tumor was speculated from the macroscopic and microscopic findings. Since repeated resections of the lung may cause the gradual deterioration of pulmonary function, the possibility of tumor enucleation will be discussed for the future treatment plan.

We report a rare case of positive findings in pleural lavage cytology（ PLC） in the patient with pulmonary adenocarcinoma in situ （AIS）. A 78-year-old woman was presented with a 30 mm pure groundglass nodule （GGN） in the left upper lobe on chest computed tomography （CT）. After 2 years follow-up, thoracoscopic surgery was performed to resect the nodule. PLC was performed before pulmonary resection. Histopathological diagnosis was 25 mm AIS. However, PLC showed positive findings of malignant cells. CT examination at 1 year and 6 months postoperatively showed pleural dissemination findings and the patient died of lung cancer at 3 years and 2 months postoperatively. PLC’s contribution to TNM staging has not yet been clarified. The positive findings in PLC and large size of pure GGN were considered likely to be poor prognostic indicators.

Case 1：A 73-year-old man was transported to our hospital for evaluation of sudden onset of chest pain, back pain, and dyspnea. We initially misdiagnosed him with advanced esophageal cancer accompanied by mediastinal metastasis；however, subsequent multi-detector row computed tomography （MDR-CT） confirmed the diagnosis. We performed coil embolization of a bronchial artery aneurysm and thoracic endovascular aortic repair（ TEVAR） to seal the root of the bronchial artery. Case 2：An 81-year-old woman with a one-week history of fever and cervical pain was diagnosed with a ruptured infected thoracic aneurysm. She underwent the same treatment as described in Case 1. Physicians should consider it as a differential diagnosis of mediastinal hematoma.

A female patient in her 40s who underwent surgery for recurrent right lung metastasis from resected ovarian cancer was referred to our department because of the right pneumothorax due to radiofrequency ablation for multiple lung metastases. Methicillin-resistant Staphylococcus epidermidis（ MRSE） was detected from the tip of the drainage catheter indicated persistent pulmonary fistula with right empyema, and surgical treatment was performed. A white coat of the whole lung surface and air leakage were observed at radiofrequency ablation （RFA） treated lesion and partial resection of the right lung, debridement, and irrigation were performed. A pathological examination revealed residual viable ovarian cancer cells and pleural fistula.

A 73-year-old man was diagnosed with left lung cancer （cT3N0M0, stageⅡB）. Left lower lobectomy and lymph node dissection by complete video-assisted thoracic surgery （VATS） was planned. At surgery, removal of the left lower lobe thorough intercostal space was difficult, and the dissection of the left 5th rib was required. After surgery, air leak appeared and reoperation was performed. At second surgery, lung injuries caused by a cut edge of the left 5th rib were found. Both lung injuries and the dissected rib were repaired, and the postoperative course was uneventful.