胸部外科

Background：Aggressive surgical treatment for renal cell carcinoma （RCC） bone metastasis has shown good results. Methods：Since January 1995, four patients underwent surgery at our institution for rib metastasis of operated RCCs. Of these patients, three were male and one was female. The patients had a mean age of 67.5 years. Except one patient who presented with rib metastasis at the time of diagnosis of RCC, the average period of metastasis to the ribs after RCC surgery was 24.3 months. All patients underwent resection of metastasized tumors involving the ribs, with or without chest wall involvement. The clinical features of the surgical treatment for RCC bone metastasis were retrospectively analyzed. Results：The mean time to tumor recurrence was 22.3 months postmetastasectomy. All patients developed other bone metastases and underwent multidisciplinary therapy. After metastasectomy, the four patients survived for 19～93 months. Conclusion：Surgical treatment for patients with rib metastases of RCC may contribute in prolonging survival.

Mycotic aneurysm of the aortic arch is a rare, but critical entity. We reviewed our surgical experience of mycotic aneurysm of the aortic arch. Between January 2007 and December 2015, we operated on six patients who had mycotic aneurysm of the aortic arch. The mean age was 72 years old, and four males were included. Preoperative white blood cell count was 18,266/μl and C-reactive peptide was 18.5 μg/dl, respectively. The initial presentations included fever（ n＝2）, hoarseness（ n＝2）, weakness of a leg（ n＝1）, dyspnea （n＝1） and hemoptysis （n＝1）. Preoperative blood cultures were positive in three patients. All patients underwent a total aortic arch repair with a four-branched vascular tube, and five received pedicled omental grafting. One patient who did not receive pedicled omental grafting died of recurrence of infection on postoperative day 21, and the other died of multi-organ failure on postoperative day 77. We experienced tracheostomy（ n＝1）, minor stroke（ n＝1）, and atrial fibrillation（ n＝1）. During the follow-up period, no recurrence of infection was observed in four survivors. Our surgical strategy is satisfactory to achieve good clinical outcomes.

Negative pressure wound therapy（ NPWT） is used primarily for tissue defects. In recent years, cardiovascular surgery via full sternotomy is increasingly performed through small incisions, but the rate of cardiovascular surgery through median sternotomy remains high in elderly patients, who frequently have complicated cardiovascular diseases. Mediastinitis, among other surgical site infections（ SSIs）, is a serious complication after cardiovascular surgery that must be resolved. Mediastinitis has a high mortality rate once it occurs, and cost of treatment and a negative impact on a patient are substantial. In some countries, NPWT is for the prophylaxis of mediastinitis, but only for cases with a significant risk of SSI. To avoid SSI, prophylactic NPWT is administered in all cardiovascular surgeries through median sternotomy at our hospital. Of 641 consecutive median sternotomy patients from March 2011 to March 2021, 601 cases were able to observe the wound for at least 30 days following the surgery. In the 601 cases, we found a statistically significant difference in the incidence of SSI. The results suggest that prophylactic NPWT significantly reduces SSI after cardiovascular surgery through median sternotomy.

A 55-year-old woman was suspected of having hilar lymph node enlargement on a routine examination of the chest computed tomography（ CT） scan at our hospital. On further examination, thoracic contrast CT and bronchial arteriography showed prominent dilation and meandering of the right bronchial artery with an aneurysm which formed a fistula to the pulmonary artery A7 at its distal end. Diagnosed as racemose hemangioma of bronchial artery with pulmonary artery fistula, we performed a surgical resection by open thoracotomy on the second day following bronchial artery embolization（ BAE）. No recurrence was observed in the five years of follow-up period after surgery. Therefore, surgical resection for asymptomatic racemose hemangioma of bronchial artery with bronchial artery-pulmonary artery fistula can be considered an effective method for the long-term prevention of bleeding.

The subsuperior segment （S*） is not frequently observed between the superior （S6） and posterior basal segments （S10）. We present a case of video-assisted thoracoscopic surgery of S6＋S* segmentectomy for a primary lung cancer patient. A 71-year-old man with a 20-mm nodule on the right S6, suspected of primary lung cancer（ cT1bN0M0, stageⅠA2）, was admitted to our hospital. Three-dimensional chest computed tomography （CT） revealed a subsuperior segmental bronchus （B*）, originating from the common trunk of the lateral basal segmental bronchus（ B9） and posterior basal segmental bronchus （B10）. In order to obtain enough surgical margin, we performed S6＋S* segmentectomy. The pathological diagnosis was invasive adenocarcinoma（ pT1cN0M0, stageⅠA3）. S* segmentectomy was considered to be useful method to ensure sufficient surgical margin when the lesion is in S* or in segments adjacent to it.

A 57-year-old man was transferred with sudden onset chest pain and evolving paralysis and numbness in the left leg. Contrast computed tomography （CT） revealed Stanford type A acute aortic dissection from the ascending aorta to bilateral internal and external iliac arteries with blood flow obstruction to the left kidney and left lower limb. Surgery was initiated 10 hours after onset of ischemic symptoms in the leg. Femoro-femoral bypass was carried out first, and we ensured sufficient phlebotomy from the ischemic limb during reperfusion and continuous hemodiafiltration to prevent myonephropathic metabolic syndrome. Total aortic arch replacement was then performed. Our treatment strategy was effective in this case of Stanford type A aortic dissection with prolonged lower limb ischemia. Although left hip disarticulation was subsequently required due to intractable infection, the patient became able to walk with an artificial limb after post-rehabilitation.

A 48-year-old woman with an abnormal shadow on chest X-ray was referred to our institution. Contrast-enhanced chest computed tomography（ CT） showed a large mass, 4.4 cm in diameter, in the right upper mediastinum. Castleman’s disease was suspected, and several vessels flowing into the tumor were identified. Since severe intraoperative bleeding was expected, preoperative embolization of the feeding vessels was performed, followed by thoracotomy and tumor extirpation. The amount of blood loss was 50 ml. The pathological diagnosis was Castleman’s disease, hyaline vascular type.

A 78-years-old woman was referred to our institution for the treatment of right subclavian artery （SCA） aneurysm. She previously underwent total arch replacement via median sternotomy approach. Preoperative computed tomography revealed a 55 mm sized SCA aneurysm. Stent graft was inserted from brachiocephalic artery to right common carotid artery via the graft anastomosed. The orifice of the right SCA was covered with stent graft inserted into the right common carotid artery-brachiocephalic artery and the right SCA was occluded with coils distal to the aneurysm, carotid-SCA bypass was performed with 8 mm ePTFE graft. Postoperative examination confirmed complete exclusion of the aneurysm and patency of the bypass graft. We thought that hybrid treatment for this patient was a less invasive alternative to conventional surgical procedure.