胸部外科

Objective:Lung cover method is now being used for primary spontaneous pneumothorax, because of the high rate of surgical recurrence. Dual cover method is used to avoid adhesions to parietal pleura in Japan. In this study, we compared the short-term results of dual cover method using Interceed, an adhesion-preventive material, with those of Surgicel Absorbable Hemostat MD. Methods:Forty-six consecutive patients who underwent surgery as primary spontaneous pneumothorax at Sapporo City General Hospital from September 2023 to July 2024 were included. The patients were divided into two groups, one using Surgicel Absorbable Hemostat MD (SCHM) on a polyglycolic acid( PGA) sheet and the other using Interceed( IC) on PGA sheet, for clinical comparisons. Results:The age of the SCHM group ranged from 12~38 years, with a mean age of 21, and IC group ranged from 16~42 years, with a mean age of 22. There was a significant difference only in operative time between the two groups, but no significant difference in blood loss, drainage time, postoperative hospital stay, or incidence of postoperative complications. Conclusions:Short-term results showed no significant difference between Surgicel Absorbable Hemostat MD and Interceed and were safe to use. Long-term outcomes, including recurrence, need to be examined in the future.

This is 4-case report of aortic valve replacement (AVR) with an On-X valve (On-X Life Technologies). Case 1 (64-year-old male) underwent AVR (23-mm valve) and mitral valve replacement, and 2 years later was diagnosed refractory pyogenic spondylitis from a traffic accident. Case 2 (57-year-old male) and Case 3( 59-year-old male) received a 21-mm valve. Case 3 had cerebellar hemorrhage without any abnormal neurological deficits in 11 years after AVR. Case 4 (65-year-old female) was implanted with a 19-mm valve. All cases have been doing well in New York Heart Association (NYHA) functional class Ⅰ or Ⅱ without any thromboembolic or major hemorrhagic events for 15, 13, 12, and 9 years, respectively. Their On-X valve performance by echocardiography were similar to those in“ On-X instructions for use” and other reports and have been maintained during the follow-up period. The On-X valve demonstrated good long-term results, although further study is needed.

The patient is a 67-year-old male. He had undergone aortic valve replacement through median sternotomy at our hospital five years ago. He came to our hospital because of respiratory distress since three months ago. Minimally invasive mitral valvuloplasty using right 4th intercostal approach was performed. Postoperative by subcutaneous emphysema worsened with time, and computed tomography (CT) scan revealed a pulmonary hernia, which was urgently repaired with a mesh plate on the same day. Pulmonary hernias after intercostal thoracotomy are rather common in small incision surgery, with a reported incidence of 1.4%. Risk factors include thoracic causing opening larger than 9 cm, obesity, chronic obstructive pulmonary disease, tissue fragility, malnutrition, steroid use, and diabetes mellitus. During mitral valve surgery, the patient had a 9 cm or larger opening, but a thread of 1 mm was placed between the ribs at the time of chest closure. Nevertheless, the thread was torn, and he developed a pulmonary hernia. A mesh plate was applied during repair with good results. Use of a mesh plate should be considered during chest closure in cases with same risk factors.

In cases of prosthetic valve endocarditis following aortic valve replacement (AVR), destruction of perivalvular tissue and discontinuity in the left ventricular outflow tract can complicate repeat valve replacement. We obtained favorable outcomes with radical resection of aortic root abscess and subsequent pericardial patch reconstruction in two cases. The first case was a 52-year-old woman who underwent patch closure of ventricular septal defect, AVR, and coronary artery bypass, one month ago. She presented with vegetations attached to the prosthetic valve and the patch. The second case was a 46-year-old male who underwent AVR for infective endocarditis. A month later, he developed heart failure due to paravalvular leakage, and computed tomography (CT) scan showed a pseudoaneurysm beneath the prosthetic valve. In both patients, surgical intervention included radical debridement of infected tissue, patch reconstruction of the defect, and AVR. Both patients were free from recurrence of infective endocarditis post-operatively.

We report the usefulness of free subcutaneous adipose tissue for the closure of a fistula in fistulous pyothorax resulting from intrathoracic perforation of a lung abscess. A 52-year-old male was admitted to our medical facility with a diagnosis of lung abscess and pyothorax. A computed tomography( CT) scan revealed a focal pleural defect of the lung abscess, resulting in the diagnosis of fistulous pyothorax. Following transfer to our department, the patient underwent thoracoscopic curettage of the pyothorax cavity, followed by fistula closure. In detail subcutaneous adipose tissue was harvested from the open chest wound and packed into the fistula for the closure of a fistula. While there is limited literature on the closure of fistulas using free subcutaneous adipose tissue in cases of fistulous pyothorax, this technique exhibits potential efficacy as a therapeutic approach.

A 74-year-old man who had undergone esophageal resection and retrosternal gastric tube reconstruction for esophageal cancer one year ago presented to our hospital with appetite loss, weight gain, and edema in both legs. He was diagnosed as having congestive heart failure secondary to mitral regurgitation, tricuspid regurgitation, and atrial fibrillation. The patient underwent total thoracoscopic mitral valve replacement, tricuspid valve annuloplasty, and maze procedure with resection of the left atrial appendage via the right intercostal mini-thoracotomy approach. Since we could not determine the cause of mitral regurgitation and the presence of the retrosternal gastric tube after his previous surgery, we were unable to evaluate the mitral regurgitation intraoperatively using transesophageal echocardiography. Consequently, we opted for mitral valve replacement instead of mitral valve plasty. In patients who have undergone retrosternal gastric tube reconstruction, minimally invasive cardiac surgery via right mini-thoracotomy is effective in reducing the risk of gastric tube injury.