胸部外科

Objectives：The purpose of this study is to assess retrospectively our treatment strategy for chronic pulmonary aspergillosis（CPA）． Patients and method：From 2002 to 2015, 11 patients underwent pulmonary resection for CPA in our hospital. Six patients were diagnosed simple pulmonary aspergilloma （SPA） and 5 were chronic progressive pulmonary aspergillosis（CPPA）. Clinical characteristics, preoperative treatment, postoperative treatment, surgical procedure, postoperative complication, recurrence, and prognosis were retrospectively reviewed．Results：Two patients of SPA and 5 of CPPA were treated with antifungal agents preoperatively. Two patients required wedge resection and 4 required lobectomy in SPA. Five patients required lobectomy in CPPA. All patients were treated with antifungal agents postoperatively. One patient presented recurrent disease in both SPA and CPPA. All patients has been alive. Conclusion：Surgical resection of CPA leads good results in selected patients. The treatment with surgery with perioperative antifungal treatment is thought to be important based on our experience.

A 60’-year-old man was referred to our hospital because of nodular shadow found at mass screening. We diagnosed the tumor as non-small cell lung cancer by transbronchial biopsy. Chest computed tomography showed a tumor shadow of 3 cm in diameter with cavity. Right middle lobectomy was performed and the pathological diagnosis was pleomorphic carcinoma of the lung. The tumor recurrence was found at 10 months after surgery, and was treated with cisplatin, docetaxel plus bevacizumab for 6 cycles. A complete remission was achieved, but regrowth at 5 months after chemotherapy was noted. The patient was treated with nivolumab following carboplatin, gemcitabine plus bevacizumab 3 cycles. A good partial response is continuing 2 years and 5 months after confirming recurrence.

An estimated 2～16％ of primary lung cancers form cavities with cases that form thin-walled cavities being comparatively rare. We treated a patient with squamous cell carcinoma of the lung with a small cystic shadow that showed no changes for 3 years. The cyst then suddenly grew larger, after which the cyst wall thickened over time and a thin-walled cavity was seen. Here we report this important case showing the development process of lung cancer that formed a thin-walled cavity, together with a discussion of the literature.

A rare case of mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation is presented. An 81-year-old woman who had undergone mitral valve repair using an annuloplasty ring 12 years earlier, was referred to our hospital because of dyspnea during exertion. As echocardiography revealed severe mitral stenosis, and redo surgery was carried out. During the surgery, fibrous tissue covered the annuloplasty ring and extended onto both leaflets of the mitral valve, which narrowed its orifice, by rendering the leaflets stiff and immobile. It was not possible to remove the fibrous tissue covering the mitral valve without damaging the leaflets. Hence, the annuloplasty ring and both leaflets were excised. The mitral valve was replaced with a 27 mm Magna Mitral Ease, and subsequently, postoperative course was uneventful.

A 47-year-old woman with a history of radiation enteritis and implantation of a central venous port was admitted to our intensive care unit（ICU） suffering from high fever. She was diagnosed with active infective endocarditis due to catheter-related blood stream infection. Although echocardiography showed a large vegetation on the mitral valve, surgical therapy was postponed for 5 weeks because of intracranial hemorrhage infarction. On the 3rd day after mitral valve repair, she developed consciousness disturbance and computed tomography（CT） revealed acute subdural hematoma of the posterior cranial fossa. Fortunately, she fully recovered from the neurological complication without surgical intervention.

The patient was a 66 year-old male. Computed tomography （CT） angiography showed a huge aneurysm（120 mm） in the aortic arch and chronic type B aortic dissection（45 mm） in the descending aorta. Echocardiography showed patent ductus arteriosus（ PDA）. Because of pulmonary hypertension due to PDA, it was considered unacceptable to put him under general anesthesia twice. We performed thoracic endovascular aortic repair （TEVAR） via the ascending aorta and total arch replacement （TAR） simultaneously to prevent paraplegia. After establishment of cardiopulmonary bypass（ CPB）， a stent graft was inserted via the ascending aorta to cover the dissection site of descending aorta, the aorta was opened under circulatory arrest, and PDA was suture closed. Another stent graft whose two proximal rows of Z-stent was removed, was inserted to descending aorta via the ascending aorta landing on the previous stent graft. The proximal end of this stent graft was anastomosed to the distal end of the prosthetic arch graft and arch branches were reconstructed as usual. The postoperative course was uneventful.

We report a case of chronic dissecting thoracoabdominal aneurysm with intraoperative retrograde aortic dissection and rupture at proximal descending aorta, which was successfully treated by echoguided stent-graft insertion. An 82-year old male underwent thoracoabdominal aortic replacement for dilatation of infra-diaphragmatic aorta. Under F-F bypass, his thoracoabdominal aorta was replaced by a Dacron graft with 4-branches. After he weaned from F-F bypass, we found massive bleeding from proximal descending aorta. Trans-esophageal echocardiography （TEE） showed aortic dissection from the clamp site to the distal anastomotic site of the former total arch replacement. We temporary got hemostasis by suture and surgical glue, and anastomosed a 10 mm-graft to the thoracoabdominal main graft as conduit, then inserted and deployed 2 pieces of stent-graft. Direct echo and TEE contributed to the accurate positioning of them. Bleeding was completely controlled. He well recovered without paraplegia. Post-operative computed tomography （CT） showed good positioning and dilatation of the stentgraft and the perfect reverse remodeling of thoracic aorta.

Surgical treatment for distal arch aortic aneurysm is generally invasive, and there is no definitive approach for it. We report 2 cases of men who was admitted for the treatment of aortic aneurysm. First case is a 78-year-old man. Two saccular aneurysm were observed on distal aortic arch and descending aorta by contrast-enhanced computed tomography. Two staged-repair was performed with using the Lupiae vascular graft and thoracic endovascular aortic repair（TEVAR）. The postoperative course was uneventful, and he was discharged on day 21 after 1st operation. Second case is a 68-yearold man. Dessecting aneurysm was observed on distal aortic arch and descending aorta 3 months after incidence of type B aortic dissection. Two staged-repair was performed with using the Lupiae vascular graft and TEVAR. However, additional TEVAR was performed for enlargement of descending aorta half a year after 1st operation. Two staged-repair using Lupiae vascular graft and TEVAR was useful for alleviating a burden of a patient and avoiding paraplegia.