胸部外科

The aim of this study is to compare the frequency of wound infection between bilateral and singleinternal thoracic artery（ ITA） harvesting in coronary artery bypass grafting（ CABG） cases. Two hundredsand thirty-four consecutive CABG cases performed harvesting either bilateral ITA （BITA） orsingle ITA （SITA） from January 2004 to December 2008, with or without concomitant surgery werestudied. Harmonic Scalpel was used for the harvesting with skeletonization technique. The cases weredivided into 2 groups；BITA group（ n＝180） and SITA group（ n＝54）.The frequencies of wound infection were 3.7％ in SITA group and 6.1％ in BITA group. As to deepsternal infection, they were 1.9％ in SITA group and 1.1％ in BITA group. There was no significant differencebetween the 2 groups.Multivariate analysis of all patients showed that emergency cases, hypertension, congestive heart failure,and reopening for bleeding were identified as independent risk factors for wound infection.There were 113 diabetes mellitus （DM） patients out of all patients；SITA group （n＝22） and BITAgroup （n＝91）. Their wound infection rates were 4.5％ and 6.6％, and those of deep sternal infectionwere 0％ and 2.2％, respectively. There was no significant difference between them.In conclusion, BITA harvesting with skeletonized technique may be used as safely as SITA harvestingeven in DM patients.

To acquire the pulmonary artery （PA） and pulmonary vein （PV） image separately, we scanned PAphase while X-ray source moved caudal direction, followed by continuous scan of PV phase by movingback reverse direction. We assessed some scanning conditions to shorten scanning time and determinedthe starting time for scanning to obtain the maximum intensity difference of radio-opaque contrastbetween PA and PV phase. Additional infusion of normal saline was followed after contrast mediumadministration. Finally, scanning could be finished almost 10 seconds with only 20 ml contrast mediumfor establish three-dimensional （3D） images of pulmonary vessels, and the residual contrast mediumcould be used for consecutive usual preoperative computed tomography（ CT）.Twenty-three patients who underwent lung resection were assessed their preoperative 3D-CTimages using 5-point scale；5 and 4 as good, 3 as fair, 2 and 1 as poor. As a result, 18 （78.3％） and 1（4.3％） were categorized as good and poor, respectively.We successfully decreased the frequency of CT and contrast agent dose for 3D-CT in patients beingscheduled for lung resection by the new methods reported herein. Additionally, the workload of buildingup 3D-CT images by medical workers was also reduced.

Background：In a pediatric setting, the need for lifetime oral anticoagulation is increasing because ofcurrency of extracardiac total cavo-pulmonary connection （TCPC） and pediatric valve surgery. Weevaluated a new compact device“ CoaguChek XS” for measuring prothrombin time-internatinal normalizedratio（ PT-INR）.Methods：The international normalized ratio（ INR） values obtained from 71 patients（ 223 samples）by a CoaguChek XS were compared with those obtained by a laboratory-based coagulation analyzer.Results：The values from the CoaguChek XS had a significant correlation with the laboratory basedresults. （ r2＝0.92，p＜0.01，regression line y＝1.05×−0.02）.Conclusion：The CoaguChek XS will be useful in pediatric management.

Cancer is known to promote its own development/proliferation and protect itself against attacks fromimmune system cells by activating the blood coagulation system. However, antithrombotic therapyinhibits the blood coagulation system.We investigated the blood coagulation system-mediated influence of preoperative antithrombotic therapyon the clinicopathological parameters of lung cancer.In patients who underwent antithrombotic therapy, there was a significant association between prothrombintime-international normalized ratio（ PT-INR and positive findings on a thoracic lavage cytodiagnosis（p＝0.02）. In these patients, the proportion of those with positive findings on a thoracic lavagecytodiagnosis was significantly higher than in those who did not undergo antithrombotic therapy （p＝0.0003）.These results suggest that cancer progression is promoted by antithrombotic therapy through theinhibition of the blood coagulation system.

Between March 2005 and September 2009, 41,827 patients visited our emergency outpatient clinic, and50 patients （0.12％） were admitted to our institution for chest trauma. Seventy percent of the chesttraumas were caused by traffic accidents. Eighty-five percent of the traffic accidents were associatedwith car driving or motorcycle driving. Rib fracture, pneumothorax, hemothorax, and lung injury wereseen in 56％, 40％, 22％, and 28％ of the patients, respectively. Chest tube drainage was performed in36％ of the patients. Sixty-two percent of the patients with chest trauma underwent conservative follow-up. Only 1 patient underwent the ligation of the intercostal artery. One patient with chest traumaand fracture of the cervical vertebra and the pelvis died, who was in the state of cardio-pulmonaryarrest on arrival. Forty-nine patients were discharged in 15.2±17.0 days. Twenty-two percent of thepatients were hospitalized only 1 night.

We report a rare case of squamous cell carcinoma of the chest wall in a patient with chronic empyema.The patient was a 74-year-old male who had been treated by closed chest drainage for empyemafor 20 years until the development of carcinoma. He received chest wall resection followed by radiationtherapy because of disseminated lesions comfirmed at surgery. However, his condition worsened gradually,and he died 2 months postoperatively.In the treatment of chronic empyema, we must pay attention to the possible association of malignanttumor for treating as early as possible, because the associated malignant tumor usually has a poor prognosis.

The patient was a 68 year-old woman who had a history of treatment of pulmonary tuberculosis 35years ago. She has experienced dyspnea and hemosputa since several years ago and has been followedup as having chronic empyema. She was admitted to our hospital due to recent exacerbation of symptoms.X-ray films and computed tomography scans of the chest showed the right thoracic cavity to betotally filled with a mass and the shift of mediastinum to the left side. After several days from admission,she needed mechanical ventilation support due to dyspnea exacerbation. Emergency decorticationwith right pneumonectomy through median sternotomy with anterolateral incision was performed.Postoperative course was uneventful. Pathlogical diagnosis was chronic expanding hematoma.

The blood spurting from the ascending aorta is uncomfortable for cardiac surgeons. To protect thesurgeons’ faces from this spurting blood, we use a longitudinal half of a plastic bottle, which is semi seethrough.While the assistant is holding this device above the ascending aorta, the surgeons can proceedthe operation with good surgical view

A 61-year-old woman who complained of chest pain and cough was admitted to our hospital. She wasdiagnosed with multiple metastasis of breast or lung cancer, and a cardiac tumor was detected by echocardiographyduring chemotherapy. The tumor was located on the papillary muscle near the apex, hada smooth surface, and was well mobile. Emergency operation was performed because the tumor wasconsidered to be a cause of cerebral infarction. Under cardiopulmonary bypass, resection of the tumorwas performed by trans-mitral-valve approach. By using a thoracoscope, we could share informationand obtain the details of the tumor during the operation. Resection using a trans-mitral-valve approachwith an aid of thoracoscopy is considered useful.

We report the graft replacement for surgical repair of coarctation of the aorta（ CoA） in 2 men, aged19 and 30 years old, respectively. In both patients, the pressure gradients were higher than 20 mmHgacross the coarctaion by cathetherization, and higher than 30 mmHg between the upper and lowerlimbs. The graft replacement of the coarctated aorta was performed under cardiopulmonary bypass.Postoperatively, the pressure gradients between the upper and lower limbs dropped below 20 mmHg inboth cases. Since about 50％ of surgically untreated patients with this disease may be expected to diebefore 30 years of age, repair of CoA in adults should be performed as soon as possible.

A 63-year-old female was admitted to our hospital for investigation of serum elevation of carcinoembryonicantigen （CEA）. She underwent high anterior resection for a rectal cancer 5-years ago. Chestcomputed tomography （CT） obtained 5-years ago showed a nodule in the right S10, measuring 1.3×0.8cm in size. The nodule was assessed as benign. Chest CT on admission showed the enlarged nodulewith a pleural indentation, measuring 2.2×1.6 cm in size. Definitive diagnosis could not be established.Since it was difficult to exclude the possibility of malignancy, video-assisted partial resection was performed.Histological examination of the nodule revealed primary adenocarcinoma in frozen sections.Lobectomy with lymph node dissection was performed. The ultimate diagnosis was adenocarcinoma with mixed subtypes. The tumor was classified as stage ⅠA with T1bN0M0. We reported this casebecause it was a rare slow-growing adenocarcinoma that had a 5-years clinical history before operation.

We report a rare case of metastatic brain and lymph node carcinoma of unknown primary origin. A68-year-old man had been followed up after resection of brain metastasis in right parietooccipital regionwithout suspicious primary site. Seventy-eight months after the resection, a mediastinal lymph node（#2R） of 15 mm in diameter was detected by computed tomography（ CT） and was surgically removed.The histological diagnosis was poorly differentiated adenocarcinoma resembling lymphoepithelial carcinoma,which was similar to the histology of the previously resected brain tumor. This patient is alivewithout recurrence and apparent primary site at 24 months after lymph node resection.

A 79-year-old female who had been observed for an intrapericardial cyst for 3 years was admitted dueto severe dyspnea and back pain. During 3 years observation, there were no symptoms and no growthof the cyst. Computed tomography scans showed rapid expansion of the cyst compared with an magneticresonance imaging （MRI） taken 9-days before when she visited our hospital for the 1st time.Urgent complete extirpation of the tumor was successfully done and a histological diagnosis found it was an intrapericardial bronchogenic cyst. This is a 1st report of intrapericardial bronchogenic cyst of whichrapid expansion is clearly demonstrated by radiology. It is suggested that complete surgical excision ofintrapericardial bronchogenic cysts at the time of diagnosis even if asymptomatic.

62-year-old man with obstructive pneumonitis due to metastatic lung cancer admitted for surgery.Anticancer chemotherapy combined with bevacizumab had been canceled 8 weeks before surgery.Right lower lobectomy and wedge resection of right upper lobe were performed. Subcutaneous emphysemaand prolonged air leakage appeared 5 days after surgery. Re-operation was performed 6 daysafter surgery, in order to control air leakage from suture line of the lung. The reason of prolonged airleakage was possibly the side effect of bevacizumab.

We report a case of successful treatment of a ruptured distal aortic arch aneurysm with cardiac tamponadeby using selective cerebral perfusion for protecting the brain. A 79-year-old man had suddenonset of severe chest and back pain. Chest computed tomography （CT） suggested an acute aortic dissection.He was immediately transferred to the emergency room of our hospital. Echocardiographyperformed on admission revealed intrapericardial fluid, and hemodynamic monitoring suggested cardiactamponade. After pericardiocentesis and removal of 400 ml bloody fluid, his hemodynamic conditionbecame stable. Enhanced chest CT showed ruptured distal aortic arch aneurysm with pericardial andpleural effusion. Emergency patch plasty of the aneurysm under extracorporeal circulation（ ECC） wasperformed, assisted by selective cerebral perfusion and deep hypothermia. The patient’s postoperativecourse was uneventful, except for minor transient respiratory troubles, and he was able return to hisusual activity.

A 58-year-old woman was admitted to our institute. Aortitis syndrome was diagnosed when she was39 years old. She developed intractable hypertension several years prior, and a computed tomography（CT） scan showed severe calcified stenosis of the descending aorta. The ankle brachial pressure indexof the right leg was 0.70 and that of the left leg was 0.63. Plasma renin activity was 4.8 ng/ml/h.Ascending aorta-abdominal aorta bypass grafting was scheduled. The operation was successfully performedunder partial cardiopulmonary bypass to control arterial blood pressure. An implanted graftwas 14 mm in diameter. The postoperative ankle brachial pressure index of the right leg was 1.07 andthat of the left leg was 1.03. Postoperative plasma renin activity was 0.2 ng/ml/h, and three-dimensionalCT revealed that the implanted graft was patent. Postoperatively, hypertension was well controlledwithout medication.

A 76-year-old woman with recurrent ball-like thrombus in right atrium after primary repair of atrialseptal defect（ ASD） and tricuspid annuloplasty was successfully treated by surgical resection and strictmanagement of anticoagulation and antiarrhythmics.A routine follow-up echocardiography, 27 months after initial operation, showed a swinging ball masslooks like a myxoma in the right atrium.Intra-operative findings showed the mass attached the free wall of right atrium with a 5 mm stalk,which was far from the ASD patch, initial suture lines, and the tricuspid annulus. Histological examinationrevealed the round and smooth mass was thrombus.She was successfully discharged 13 days after the 2nd operation without any complaint. A postoperativelaboratory check demonstrated normal coagulability. Despite the patient was prescribed warfarinpotassium and aspirin, the follow-up echocardiography at 3 months showed a recurrent thrombus in theright atrium. However the strict anticoagulation therapy with warfarin potassium and aspirin inducedthrombolysis and prevent any embolic event, 1 month later. It is important to continue a strict anticoagulanttherapy and prevent arrhythmia to avoid recurrence thrombus.

A female with autism, aged over 40 years, who had been hospitalized in a nursing home, developeddescending necrotizing mediastinitis requiring tracheostomy. Subsequently, tracheal stenosis wasobserved. She was referred to our hospital. T-tube therapy was selected, and there has been no recurrenceduring the 3-year follow-up. We report a patient in whom a T-tube was useful for treating benigntracheal stenosis in the presence of autism.

The case was 74-year-old woman. A tumor at the aortic window was found while retrieving thecause of the hoarseness, and the surgical biopsy was performed. The diagnosis of the leiomyosarcomawas obtained by pathology, and it probably originated from the middle mediastinal tissue. The radicaloperation was not selected, and the radiation therapy was performed. She did not suffered from symptomsassociated with cardiopulmonary dysfunction, but she died of the cerebral metastasis in 5 monthsafter the biopsy.