胸部外科
・1948年創刊。常に最近の話題を満載した、わが国で最も長い歴史と伝統を持つ専門誌。
・心、肺、食道3領域の外科を含む商業医学雑誌として好評を得ている。
・複数の編集委員(主幹)による厳正な査読を経た投稿論文を主体とした構成。
・巻頭の「胸部外科の指針」は、投稿原稿の中から話題性、あるいは問題性のある論文を選定し、2人の討論者による誌上討論を行っている。
・胸部外科医にとって必須の特集テーマを年4回設定。また、「まい・てくにっく」、「1枚のシェーマ」、読み物として「胸部外科医の散歩道」を連載。
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特集【呼吸器の胸部外傷】
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- 1.胸部外傷でkey となるcase
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肺刺創による左室空気塞栓
77, 4(2024);View Description Hide DescriptionA man in his 50s was stabbed deeply in the back with a knife and brought to the emergency room. He was found to have a significant left hemopneumothorax. He was planned to undergo hemostatic surgery under general anesthesia. However, shortly after the change in a right lateral decubitus position, he experienced ventricular fibrillation. Hemostasis of the intercostal artery injury, the source of bleeding, and suture of the injured visceral pleura were performed under extracorporeal membrance oxgenation(ECMO). Although sinus rhythm was resumed, when positive pressure ventilation was applied to the left lung for an air leak test, ST elevation on the electrocardiogram and loss of arterial pressure occurred. A transesophageal echo revealed air accumulation in the left ventricle. It was determined that air had entered the damaged pulmonary vein from the injured bronchi due to the stab wound, leading to left ventricular puncture decompression and lower left lower lobectomy. Subsequently, his circulatory status stabilized, and ECMO was weaned off. He recovered without postoperative neurological deficits postoperatively. The mortality rate for chest trauma with systemic air embolism is very high. In cases of deep lung stab wounds, there is a possibility of systemic air embolism, so treatment should consider control of airway and vascular disruption during surgery. -
外傷性気管・気管支損傷の治療経験
77, 4(2024);View Description Hide DescriptionBackground:Tracheobronchial injuries resulting from blunt trauma are relatively rare among chest injuries. However, if these injuries are not managed properly, they can be fatal. The prognosis is intricately linked to the precise diagnosis and treatment. We herein report three cases of tracheobronchial trauma that required surgical intervention. Case 1:A 17-year-old male sustained injuries when his torso became entangled in heavy machinery. The diagnosis revealed a tear in the right main bronchus, which required transportation with left single-lung ventilation. The patient was treated by tracheobronchial reconstruction. Case 2:A 71-year-old male experienced trauma when his car collided with a utility pole. He was transported to the hospital after tracheal intubation due to a laceration of the tracheal membranous area. The site of the injury was closed with sutures. Case 3:A 17-year-old female who had been struck by a train suffered acute respiratory failure and was transported to the hospital after intubation. Veno-venous extracorporeal membrane oxgenation (VV-ECMO) was initiated in response to poor oxygenation. Complete rupture of the right middle bronchial trunk and laceration of the right main bronchial membrane were observed, and bronchoplasty was performed. Conclusion:A swift and accurate diagnosis, coupled with timely and judicious therapeutic interventions, play a pivotal role in managing tracheal and bronchial injuries. -
経皮的静脈脱血-静脈送血の体外式膜型人工肺下に左肺全摘,気管支断裂修復を行い救命しえた外傷性左主気管支断裂
77, 4(2024);View Description Hide DescriptionA 60-year old woman, sandwiched between two boats was brought to our hospital with severe respiratory failure. She was in pre-shock and there was extensive cutaneous emphysema from the face to abdomen. She required respirator support and bilateral chest tubes for hemopneumothorax. On the patient’s 3rd hospital day, she received venovenous extracorporeal membrance oxgenation( ECMO) due to sudden ventilatory failure. The bronchofiberscopy revealed complete disruption of the left main bronchus and occlusion of the right one owing to blood clot and sputum. Because of significant destruction of the left main bronchus, we didn’t attempt bronchoplasty, and performed left pneumonectomy under veno-venous (VV)-ECMO. The postoperative course was uneventful, and she was discharged after 30 days with satisfactory outcome.
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まい・てくにっく
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特集【呼吸器の胸部外傷】
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- 2.胸部外傷における総論とアプローチ
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胸部外傷手術例の治療成績
77, 4(2024);View Description Hide DescriptionBackground:Intra-thoracic organ bleeding and chest wall injury following chest trauma can easily lead to life-threatening emergencies and a delay in treatment may lead to fatal outcomes. Interestingly, the optimal timing, indications, and surgical techniques have not been standardized. Method:We retrospectively analyzed 35 patients who underwent surgical treatment for chest trauma. Results:All patients with penetrating trauma (n=4) underwent emergency surgery for a hemothorax. There were no postoperative complications or hospital deaths. All patients with blunt trauma( n=31) had multiple rib fractures;rib fixation was performed in 29 patients( 94%). Eight patients( 26%)had flail chest. The duration from injury to surgery averaged 7.5 days. The prognosis was generally favorable with no postoperative complications, but two patients died in the hospital due to multiple organ failure caused by high-energy trauma. Patients with flail chest or multiple organ injury had prolonged postoperative hospital stays. Conclusions:Patients who sustain chest trauma follow various clinical courses. Appropriate timing of surgical intervention at an early stage after injury can be life saving and hasten a functional recovery. -
胸部外傷に対する胸腔鏡下手術
77, 4(2024);View Description Hide DescriptionVideo-assisted thoracoscopic surgery (VATS) is now commonly used in emergency surgery to confirm the site of injury and observe the thoracic cavity, especially in cases of chest trauma with stable vital signs. VATS was used in all 33 chest trauma surgeries performed at our department from October 2009 to July 2023. The common injury mechanisms were traffic trauma and falls, but there were also cases of trauma from a bullhorn, heavy machinery and farm equipment, and penetrating injury. The common surgical procedures were treatment of rib fractures and pulmonary suture or partial lung resection, followed by treatment of diaphragmatic injuries. Unusual surgical procedures included extrapleural hematoma drainage, pericardial drainage, hemostasis of intrathoracic bleeding from thoracic vertebral fracture, and lobectomy for airway bleeding. Here, we report our surgical policies and techniques for chest trauma. First, the thoracic cavity should be observed thoracoscopically to determine the site of injury. The key to repair is placement of a small thoracotomy directly above the rib fracture site, where dislocation is largest, followed by suture repair of the lung and diaphragm by combining direct and thoracoscopic views. - 3.肋骨・胸骨固定の現在
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肋骨固定術を施行した胸部外傷70例の検討―適応と施術の実際的工夫
77, 4(2024);View Description Hide DescriptionWe summarized the experience of surgical stabilization of rib fractures (SSRF) at a core hospital in eastern Hiroshima, which is a primary center for tertiary emergency medical care, especially for high-energy trauma cases including chest injuries. The study focuses on patients who underwent SSRF from January 2016 to September 2023, analyzing patient characteristics, injury mechanisms, associated injuries, fracture locations, time from injury to surgery, fixation devices used, and postoperative outcomes. Our hospital primarily treats elderly patients, and falls are the most common cause of injury, followed by traffic accidents. The criteria for SSRF in our hospital were clinical manifestations of flail chest, need for lung repair, persistent pain, or improvement of thoracic deformity. We had a high rate of fixation of fractures of the 4th-10th ribs, which have a significant impact on respiratory mechanics;although KANI plates were primarily used, the introduction of MatrixRIB plates offers advantages in certain scenarios. The study also identified challenges with the KANI plate, including cases of plate dislodgement, particularly in patients with multiple fractures and severe thoracic deformities. The combination of video-assisted thoracoscopic surgery and SSRF allows for more effective rib fixation and reduces surgical wound size and muscle damage.