Search

43歳，女性．健診で縦隔腫瘍を疑われ当院受診，胸部CT，血液生化学的諸検査などが施行された．CA19-9の高値（108U/ml），前縦隔に約3×4cmの隔壁を有する嚢胞性病変が認められ，手術が施行された．腫瘍は左前縦隔に存在し，胸腺左葉と連続しており，左上葉，左縦隔胸膜とも強固に癒着していた．左上葉の部分切除と癒着した縦隔胸膜とを一塊にして胸腺摘出術を施行した．病理診断は膵組織を伴う成熟型奇形腫であった．術前上昇していたCA19-9は術後正常化し，腫瘍内産生が示唆された．成熟型奇形腫は診断時に無症状であっても周囲組織と強固な炎症性癒着を起こし，合併切除が必要になることがあり，注意を要すると考えられた．

症例は54歳女性．2005年6月会社の健診にて胸部異常陰影を指摘され当院呼吸器内科に紹介となった．胸部CT検査で右中葉胸膜直下に辺縁不整な10mm大の結節影を認められたがPET検査は陰性であったため経過観察されていた．しかし2006年1月のCT検査で肺癌の可能性も否定できず確定診断，治療目的で当科に紹介となり胸腔鏡下手術を施行した．迅速病理検査で血管腫と診断され，病理組織学的検査で毛細血管腫（capillary hemangioma）と最終診断された．術後経過良好で合併症もなく軽快退院となった．肺の孤立性の毛細血管腫についての報告は極めて稀であり文献的考察を加えて報告する．

症例は55歳，女性．意識消失発作にて，精査が施行された．頭蓋内病変は認められず，24時間ホルター心電図にて2:1高度房室ブロックが認められた．そのため，意識消失はAdams-Stokes発作と診断され，ペースメーカー（Pacemaker:PM）植込み術の予定となった．しかし，金属アレルギーの既往があったため，外来にて金属パッチテストを施行した．PMに使用されている金属にアレルギーは認められなかったが，予防的にPM本体をpolytetrafluoroethylene（PTFE）シート（ゴアテックスシート®）にて被覆し，植込み術を行った．植込み後12カ月が経過したが，PM植込み部のトラブルは生じていない．PMアレルギーのためPM植込み部の皮膚炎を繰り返す症例に対し，PTFEシートを使用した報告はいくつかある．今回われわれは，予防的PTFEシート被覆にてPM植込み部トラブルを回避した，金属アレルギーの1症例を経験したため，報告する．

症例は55歳の男性. 平成17年10月中旬に胸部不快感のため近医受診し, 発作性上室性頻拍と診断され内科的に加療されるも心房細動に移行したため当院循環器内科に紹介となった. EPSにてKENT束を持つ潜在性WPW症候群と診断されたが, 心臓超音波検査で僧帽弁後尖に付着する腫瘍を認められ, 手術目的で当科紹介となった. 準緊急的に腫瘍切除, 僧帽弁形成術および副伝導路切断術を施行した. 病理組織学的検査で乳頭状弾性線維腫と診断された. 術後は洞調律で経過し, EPSにてKENT束の離断を確認した. 現在, 不整脈や腫瘍の再発を認めず, 同時手術は有用であった.

大動脈四尖弁は発生頻度が非常に低く,大動脈弁閉鎖不全に対する手術例の報告も少ない.今回われわれは,経食道および経胸壁心エコーにて術前に大動脈四尖弁による閉鎖不全症と診断し,弁置換術を施行した症例を経験したので報告する.症例は37歳男性で,左胸部違和感を主訴に来院した.経食道および経胸壁心エコーを施行したところ,大動脈四尖弁による閉鎖不全症と診断された.心臓カテーテル検査にて大動脈閉鎖不全(AR) III度と診断され,手術適応として当科紹介となった.術中所見では左右冠尖が同大で,無冠尖と過剰弁は同大であるが他の2つに比してやや小さかった.手術は人工弁にて弁置換術を行い,経過は良好であった.

肩・鎖骨などの整形外科的手術で固定に用いる鋼線の術後の移動・迷入はまれな合併症であると言われているが我々は2例の胸腔内迷入症例を経験したので報告する.症例1は34年前に左胸鎖関節脱臼のため固定術を受けた56歳男性で, 他病で入院した際の胸部X線検査にて縦隔内に存在する金属性異物を指摘された.胸部CTでは前縦隔内大動脈弓部の前方に位置していたため, 胸腔鏡下摘出術を行った.症例2は右鎖骨骨折に対して経皮的整復固定術を受けた71歳女性で, 3ヵ月後に発熱のため撮影した胸部X線写真にて, キルシュナー鋼線 (2本) の移動を認めた.先端がそれぞれ肺実質内と縦隔内の血管の間に達していたため右開胸にて除去した.心血管系の損傷を起こして死亡した症例の報告もあり, 固定用鋼線の移動・迷入が確認された場合には症状の有無にかかわらず早期の摘出術が必要である.

症例は79歳男性.腹部大動脈瘤手術後9年目に間歌性下血を呈し精査中に, Y型人工血管置換部中枢側に約6cmの腹部大動脈瘤の再発を認めた.下血症状は消失し, I型人工血管術を施行した.腹部大動脈と腸管との間に瘻孔はなかったが,術後4日目に再度間欺性の下血症状が出現し,術後8日目には大量下血によるショック症状を呈し緊急開腹手術となった.骨盤腔内の癒着した小腸を剥離すると,Y型人工血管左脚の吻合部から約2cm離れた部位に外腸骨動脈瘤腸管瘻があり,手術にて救命できた.動脈瘤腸管瘻は下血の原因としては稀であるが,術前診断が困難であるだけでなく,手術時期が遅れると致死的となる.腹部大動脈瘤術後9年目に間歌性下血で発症したことで,診断に苦慮したが,早期診断のためには本疾患も念頭に置き精査する必要があると思われる.

症例は58歳女性.検診で胸部X線写真で異常陰影を指摘され当院受診した.胸部CT検査, MRI検査で巨大な心膜嚢腫を疑われた.胸腔鏡下に嚢胞内貯留液を吸引することで容易に巨大嚢腫を切除できた.嚢腫は心膜と連結していたが交通はなく,病理組織学的診断は心膜嚢腫であった.心膜嚢腫は比較的稀な疾患であるが,本症例の如く嚢胞液中の腫瘍マーカー (CA19-9, CA125) が異常高値を示した巨大な心膜嚢腫を胸腔鏡下に切除した症例の報告はない.心膜嚢腫は悪性化の報告もあり,積極的な外科的切除が望ましいと考えているが,胸腔鏡下手術は術中の病理学的検査で確定診断が得られ,嚢腫内容液の吸引することで容易に心膜から剥離切除でき理想的な治療法と考える.

中皮腫は漿膜最上層のmesothelial cellを発生母地とする腫瘍である.われわれは,肉眼的に限局した形態で発見された悪性胸膜中皮腫の1例を経験したので報告する.症例は57歳,男性.胸部異常陰影にて入院した.精査にて横隔膜原発腫瘍を疑い胸腔鏡下切除術を施行した.術中迅速病理にて悪性所見を認め,肺,横隔膜にも浸潤していたため右肺下葉,横隔膜の一部を合併切除した.術後の病理組織検査にてmalignant mesotheliomaが疑われ,免疫組織学的検討にてCytokeratin陽性, Vimentin陽性, CD34陰性であった.その後2度局所再発し,手術と化学療法を施行し,現在外来通院中である. malignant mesotheliomaは診断が困難であるが,他疾患との鑑別に免疫組織学的検索が非常に有用である.現在本疾患に対する有効な治療法はなく,予後も極めて不良と言われる.新たな治療法の解明のためにも他疾患との明確な鑑別診断が必要と考える.

The aim of this study was to estimate the results of abdominal aortic aneurysm (AAA) repair with or without coronary artery disease (CAD), retospectively. We studied the incidence of associated CAD among 47 consecutive patients operated upon for AAA, excluding ruptured aneurysms. The screening of CAD was routinely performed by coronary angiography. More than 50% luminal stenosis of the major coronary artery was judged positive for CAD. Twenty-five of the 47 patients (53%) had CAD of 25 patients, 14 patients were subjected to pharmacotherapy, and 11 were indicated coronary revasculization. Nine of those patients underwent successful PTCA prior to surgery. The remaining two patients were considered to be unsuitable for PTCA and underwent coronary bypass grafting before AAA repair. There was no operative mortality or perioperative myocardiac infarction during and after the repair of AAA. This study seggests that AAA repair with CAD could be performed saflely by means of the detailed preoperative evalution and that PTCA or CABG should be approached aggressively in cases with CAD prior to AAA repair.

われわれは,大動脈弁原発の乳頭状弾性線維腫の1例を経験したので報告する.症例は71歳,女性.畑仕事中に倒れ当院へ緊急搬送され脳梗塞の診断で入院加療されていたが,心エコーにて大動脈弁左冠尖に3×10mm大の疣贅エコーあり,当科紹介となった.全身状態の改善を待ち手術を施行.人工心肺下に手術を行った.左冠尖弁尖に約10mm大の茎を有するイソギンキャク様の腫瘍を認めた.腫瘍切除のみ行い大動脈は温存した.病理組織学的に乳頭状弾性線維腫と診断された.術後は合併症なく順調に経過した.心臓原発の腫瘍は稀であり,その7割は良性腫瘍である.しかし乳頭状弾性線維腫は脳梗塞や心筋梗塞といった重大な合併症をきたしうるため,発見次第早期に摘出をすることが推奨されている.

We report the successful surgical treatment of a rare case of chronic expanding hematoma in the pericardial cavity that developed into a very large mass over a long period. The patient, who had a history of cardiac surgery for a double-outlet right ventricle 14 years previously and for tricuspid regurgitation 8 years ago, noticed a slowly growing mass near the left atrium and ventricle 5 years ago. The mass, which confirmed a diagnosis of chronic expanding hematoma, was resected by left thoracotomy.

We report three cases of iliac artery rupture during percutaneous transluminal angioplasty (PTA). In all three cases, bleeding was temporarily controlled by inflating an angioplasty balloon at the site of bleeding. Two patients underwent subsequent surgical revascularization, and one underwent endovascular stent grafting but ultimately required a surgical bypass. Arterial rupture is a rare but potentially fatal complication of PTA. Although stent grafts for peripheral arteries are not yet covered by Japanese medical insurance, it is a useful treatment for arterial injury during PTA.

最近5年間に手術した腹部大動脈瘤56例のうち破裂性腹部大動脈瘤は12例 (21%) であった. 12例中9例が来院時にショック状態であり, うち3例に心マッサージを要した. 初期に手術した直接開腹群4例のうち, 大動脈遮断に至るまでに出血性ショックで臓器不全となり病院死3例 (75%) を経験した. 他の8例は小さな左前側方開胸を加えて下行大動脈遮断が可能な状態で開腹した. このうち術前ショック状態が重篤であった4例は下行大動脈遮断を平均21分行った. 病院死は8例中1例 (12.5%) に減少した. 動脈瘤の最大径は左開胸群と非開胸群との間で差はなく, 手術時間も差はなかった. 出血量は左開胸群が平均3,925mlに対し直接開腹群は平均7,193mlであった. 開胸の合併症として, 肺炎と黄疸を1例ずつ経験したが軽快した.

The dual puncture is one of the diseaseful complications at the induction of the epidural anesthesia, which causes severe symptoms of intracranial hypotension such as headache and nausea. The clinical courses of 3 patients with the dual puncture symptoms after pulmonary resections were retrospectively reviewed, and the effect of the continuous epidural saline infusion treatment (CESI) for the dual puncture was evaluated. Pneumococcal empyema developed in 1 patient who had been treated with conservative management. In contrast, the symptoms of the others who were treated with the CESI were quickly recovered or were effectively prevented. This report strongly suggested that the CESI was convenient and effective treatment for dual punctune symptoms by suppressing the cerebrospinal fluid leakage by elevation of the fluid pressure in the extradural space.

Using transesophageal echocardiography during open heart operations, we found another form of retained intracardiac air, "pooled air," in addition to the form of "bubbles" that had been reported by other authors. The pooled air was detected in all of 13 patients (100%); it was located at the right upper pulmonary vein in 13 (100%), left ventricular apex in 9 (69.2%), left atrium in 8 (61.5%), right coronary sinus of Valsalva in 8 (61.5%), left atrial appendage in 4 (30.8%), and left upper pulmonary vein in 3 (23.1%). The pooled air was found also in the pulmonary artery in 6 of 8 patients (75.0%) in whom the pulmonary artery was clearly visualized. In 1 patient, 5 mL of air was aspirated from the left ventricular apex, followed by a reduced size of the air on the transesophageal echocardiographic image. Because intracardiac air rapidly changes its locations and appearances, continuous monitoring is important, especially at weaning from bypass. The long-axis view of the heart is useful not only for detecting and locating the air, but also for guiding and evaluating the procedures to remove air.

Venous aneurysm (VA) is a rare vascular lesion. The authors have experi enced 2 cases of VA: a seventy-year-old woman who had a 4 x 4 cm VA at the elbow and a forty-five-year-old woman who had a 1.5 x 1 cm VA in the long saphenous vein. In the second case, intraaneurysmal observation was per formed by angioendoscopy during surgery. Histologic examination of the re sected lesion proved that the basic structure of the venous wall was preserved in both cases, although a marked reduction in each component of wall was ob served. The authors reviewed the reported cases of VA and classified them into type I VA (cystic ectasia) and type II VA (fusiform ectasia). Type I VA is predominant in extremities and internal organs, while type II VA predominates in the cervical region. Their analysis of the reported cases indicated that although VA and varicose veins are both venous ectasias, VA is distinguishable from varicose veins by the following features: no sex difference, occurrence even in children, occurrence anywhere in the body, occurrence as a single lesion, and lack of prolongation of the vein.

We report a case of a 45-year-old man with thymic carcinoids in multiple endocrine neoplasm-type 1. Extended total thymectomy was performed through a median sternotomy, and the mediastinal regional lymph nodes and fibroadipose tissue were dissected. Multiple endocrine neoplasm-type 1 related thymic carcinoids are rare and have a poor prognosis. The efficacy of radiotherapy and chemotherapy for prolonging survival is limited, and an aggressive surgical approach with complete excision of the tumor with resection of the peripheral tissues and dissection of the mediastinal lymph nodes seems to be the best available treatment today. We have found that this practice of thymectomy at an early stage in combination with genetic and effective radiological treatment can be effective for multiple endocrine neoplasm-type 1 patients.

We report a rare case of a 58-year-old man of long-term survival after surgical treatment of solitary metachnonous jejunum and duodenum metastasis from lung cancer. He underwent right upper lobectomy with a diagnosis of lung cancer which was histologically diagnosed as large cell carcinoma (pT4-MONO, stage IIIB). One month after the operation, he suffered from ileus caused by metastasis in the jejunum. Partial resection of the jejunum and postoperative chemotherapy were performed. Two years after the 2nd surgery, another metastatic tumor was found in the duodenum, and pancreatoduodenectomy was performed. The postoperative course of the patient was uneventful without recurrence 6 years after surgical resection of lung cancer.

希な膝窩動脈外膜嚢腫の2例を経験した. 症例1は51歳の女性で, 主訴は歩行時の下肢倦怠感, 疼痛であった. 症例2は34歳の男性で, 主訴は膝屈曲時の下肢しびれ感であった. 両者とも血管造影では三日月状の狭窄がみられ, CTでは動脈周囲に cyst 様病変が描出された. MRIではT2強調画像で高輝度の腫瘤であった. 外膜嚢腫の診断にて嚢腫壁切除術を施行し, 良好な成績が得られた. 外膜嚢腫は希な疾患で, これまで本邦では43例しか報告されていないので, 報告例を集計して疾患の特徴を明らかにした. 臨床症状は間歇性跛行を呈することが多く, 閉塞性動脈硬化症 (ASO) と似ているが, ASOと異なりバイパス術を必要とすることは希で, ほとんどは嚢腫壁切除のみで治癒する. 若年者で間歇性跛行をみた場合には, 本症の存在を頭において血管造影, 超音波, CT, MRI等の検査を行ってASOとの鑑別を行う必要がある.

希な炎症性腹部大動脈瘤の1例を経験した. 症例は78歳の男性で, 腹部腫瘤を主訴に来院した. 血液検査で軽度の炎症反応を示し, CT検査で直径5.5cmの腹部大動脈瘤であった. 瘤壁は著明に肥厚しており (外套徴候), 高輝度に描出された. 人工血管置換術を行い, 良好な成績がえられた. 瘤壁の病理組織学的所見では, 外膜にリンパ球, 形質細胞等の慢性炎症細胞浸潤が高度に認められた. 本症の本邦報告例10例を集計し, 年齢, 性別, 症状, 炎症反応の有無, 合併症, エコーやCT所見, 病理組織学的所見につき検討するとともに, 本症の原因, 診断, 治療に関して若干の考察を加えた.

We report a relatively rare surgical treatment for two cases of inflammatory pseudotumors of the lung. In case 1, a 52-year-old male with a history of left chest pain was admitted to our hospital for an abnormal nodule with an irregular margin that was detected in the left upper lung field. The nodule, measuring 15 mm in diameter, was larger than the one observed six months earlier, which had been removed by a thoracoscopic resection. In case 2, a 64-year-old female with a history of chronic cough and hemoptysis was admitted to our hospital, and an abnormal nodule with pleural indentation was detected in the lower left lung field. The nodule, measuring 8 mm in diameter, was also removed by a thoracoscopic resection. In both cases, the histologic examination enabled us to diagnose the lesion as an inflammatory pseudotumor. In general, it is very difficult to differentiate inflammatory pseudotumors from malignant tumors of the lung. The best treatment for inflammatory pseudotumors is usually early and complete surgical resection, since it can lead to improved survival. Therefore, we consider thoracoscopy-aided surgery to be less invasive and more useful than other surgical methods in the diagnosis and treatment of inflammatory pseudotumor of the lung.

A case of catheter embolization of the bronchial arterial collateral for chronic pulmonary embolism (PE) is reported. A patient suffering massive hemoptysis was diagnosed by bronchoscopy and bronchial arteriography as having PE with large bronchial arterial collaterals. Since the left iliac vein was thrombosed and multiple PE was revealed by angiography, it was thought that chronic PE, caused by iliac vein thrombosis, produced large bronchial arterial collaterals and caused bleeding. Catheter embolization of the right bronchial arterial collateral was suc cessfully employed, and hemoptysis ceased.

Several operative procedures for funnel chest were adapted during recent 15 years. Before 1977, sternal elevation and simple sternal turnover were the standard procedures. Since 1978, sternal turnover procedure preserved with the abdominal rectal muscle were used for 125 cases. This procedure had several advantages, such as good wound healing and comestic superiority of the sternum. But postoperative follow up survey in 1986 revealed a moderate degree of sternal protrusion and costal excavation in 41% cases. Then, the modified sternal plasty was deviced which was changed from the sternal turnover procefure with the abdominal rectal muscle but the sternum was not turned. This new procedure has the physiological cavature in shape and clinical application to 7 cases was resulted in satisfactory outcome.

A study was undertaken to evaluate the validity and efficacy of video-assisted thoracic surgery (VATS) for the diagnosis of indeterminate pulmonary nodules.Between April 2001 and November 2004, 57 adult patients (31 males, 26 females) with a clinical diagnosis of pulmonary nodules by preoperative chest computed tomographic (CT) scanning were included in this study.A definitive tissue diagnosis was obtained in all 57 patients. The mean age of the patients was 66+/-9.8 yrs. The mean size of the tumor was 1.76+/-0.67 cm. 38 patients (67%) had malignant disease. Twenty eight patients (49%) had primary lung cancer and 10 patients (18%) had metastatic lung cancer from an extrathoracic primary neoplasm. The rate of malignancy was 65% in the tumor sizes equal to or less than 2 cm. Among primary lung cancer, most patients had primary adenocarcinoma (24 cases)(86%). Pathologic staging showed T1N0 (stage IA) in 18 cases (69%), T2N0 (stage IB) in 4 cases (15%), T2N1 (stage IIB) in 1 case (4%), and T1N2 (stage IIIA) in 3 cases (12%). In 10 patients (18%) who required preoperative placement of a localization hookwire with a string near the nodule, the rate of malignancy was 70%. In 7 patients with positive positron emission tomography (PET) imaging with F-18 fluorodeoxyglucose (FDG), the rate of malignancy was 57% and proved to be falsely positive in 3 cases (43%). There was no operative mortality and no significant morbidity in all cases.We proposed that VATS, which is safe and offers virtually 100% sensitivity and specificity, should be performed for most small (3 cm in diameter) and all indeterminate pulmonary lesions on the basis of these results.

We report on the rare and surgical treatment of a case of primary mediastinal liposarcoma. A 64-year-old male complained of hoarseness for one month and was admitted to our hospital because of an abnormal shadow, which was postulated to be an anterior mediastinal tumor on a chest computed tomography (CT) scan. Horizontal T1-weighted magnetic resonance imaging (MRI) showed an anterior mediastinal round mass with a signal intensity similar to that of subcutaneous fat, which was 6.5 cm in diameter. An operation similar to extended thymectomy was perfomed through a median sternotomy. Histological examination of the resected specimen revealed that the tumor was composed of well-differentiated liposarcoma and pleomorphic malignant fibrous histiocytoma and the tumor was diagnosed as a de-differentiated liposarcoma. We discuss it with reference to a collective review of the Japanese literature for surgical cases of primary liposarcoma of the mediastinum.

We report on the rare and surgical treatment of a senile patient of infected intralobar pulmonary sequestration. A 56-year-old male who had complained of headache, vomiting, cough, sputum production, and high fever was admitted to our hospital. Chest computed tomography (CT) showed an infected intralobar pulmonary sequestration as an 8x6 cm cystic mass with multiple air-fluid cavities in the left lower basal segment and severe pneumonia in the left upper and lower lobes around the mass. A 3-D CT showed an aberrant artery entering the consolidation from the descending aorta. A standard lower lobectomy was performed with a ligation of the aberrant artery with a diameter of 1 cm supplying the posterior segment of the left lower lobe. A histological examination of the lung revealed acute and chronic broncho-bronchiolitis with cystic dilatation consistent with intralobar pulmonary sequestration. We discuss the characters of senile patients compared with juvenile patients, with reference to a collective review of patients older than 50 reported in the literature.

We report on the rare and successful surgical treatment of a case of spontaneous rupture of the ascending thoracic aorta resulting in a mimicking pseudoaneurysm. A 72-year-old male who had complained of sudden onset of severe chest pain was admitted to our hospital. Initially, acute type A closing aortic dissection was suspected because computed tomography (CT) showed a small ulcer-like projection (ULP) in the posterior aspect of the ascending aortic wall, but it also revealed no intimal flap, false lumen or aortic aneurysm. CT and magnetic resonance imaging (MRI) indicated a change in the radiographic aspect of the ULP and revealed a mimicking saccular-type pseudoaneurysm and gradual increasing size of the pseudoaneurysm. Surgery was performed after considering the risk of pseudoaneurysmal rupture. We replaced the ascending aorta and diagnosed it as a spontaneous aortic rupture by histological examination of the rupture site after failing to observe an aneurysm or dissection. We discuss these results with reference to the literature, including our pathological and radiographical findings.

A 61-year-old male had complained of cough and dyspnea on effort, with right pleural effusion. Computed tomography demonstrated a calcific pericardium surrounding the entire heart, with thickening of 10 mm. Cardiac catheterization showed no coronary disease, but a dip-and-plateau of the pressure curve of both ventricles. We diagnosed congestive heart failure due to chronic constrictive pericarditis, and performed a subtotal pericardiectomy, using an Ultrasonic Scalpel through a median sternotomy combined with anterior left thoracotomy at the level of the fifth rib, without cardiopulmonary bypass (CPB). After the subtotal pericardiectomy, his postoperative recovery was uneventful and his functional status improved. We consider that our surgical technique is a useful method for treatment of chronic constrictive pericarditis, and advocate the use of the Ultrasonic Scalpel for a safe and easy pericardiectomy.

We report a 58-year-old man who underwent surgical treatment of primary lung cancer arising from the wall of a giant bulla. Chest roentgenography and computed tomography revealed multiple emphysematous bullae in the bilateral upper lobes, and a right upper giant bulla with a mass measuring 6 cm arising on the bulla wall. Right upper lobectomy was performed, the postoperative pathological diagnosis was large cell carcinoma arising from the wall of a giant bulla. Although the postoperative course was uneventful and he was discharged, he underwent partial resection of the jejunum for recurrence of carcinoma in the jejunum, and postoperative chemotherapy, and he was alive 20 months after that operation. In general, patients with both pulmonary bullous disease and primary lung cancer have a very poor prognosis, because they receive treatment when the tumor is at an advanced stage. On the basis of our review of the literature, we recommend that middle-age male patients with a giant bulla who smoke should have annual chest roentgenography and/or chest computed tomography to screen for lung cancer arising in or close to the bullous disease, and that a giant bulla should be resected in patients older than 50 years because of the high incidence of coexisting cancer and bulla, to improve the prognosis of this disease.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.

The performance of cardiac surgical procedures via median sternotomy in a patient with a tracheostomy can result in difficult problems, such as mediastinitis, stoma necrosis or inadequate operative exposure. We present a case of successful treatment for aortic valve regurgitation in a patient with a tracheostomy using a T-shaped sternotomy instead of a usual median sternotomy. This approach permitted adequate surgical exposure for cardiopulmonary bypass and aortic valve replacement. After surgery, the patient had a good clinical course without any complications and he was discharged on the 65th postoperative day. We consider this procedure to be applicable in consideration of the favorable results obtained.

We performed surgical treatment for abnormal echoes in the left ventricular outflow tract caused by ruptured mitral chordae tendineae. An asymptomatic 68-year-old man had a chordal rupture exhibiting a tumor-like lesion in the left ventricular outflow tract on echocardiography. Considering a high level of mobility of the tumor as well as its texture, the risk of embolization was found to be significant. Therefore, it was decided on the surgical resection of the tumor-like lesion under extracorporeal circulation. We report a highly rare case of rupture in redundant mitral chordae tendineae without mitral regurgitation, revealed by uncommon echoes in the left ventricular outflow tract during systole.

We report a very rare case of primary malignant lymphoma arising in the pleura with no history of persistent pyothorax. A 72-year-old male was hospitalized with dyspnea on effort and chest CT demonstrated a mass along the right chest wall. Right thoracotomy with complete en bloc resection of the pleural tumor was performed. Immunohistochemical examination of the pleural tumor showed that the histology was marginal zone B-cell malignant lymphoma. We considered that this tumor had originated from the soft tissue in the chest wall based on radiographical and surgical findings. As diagnosis and treatment of pleural malignant lymphoma seems to have been difficult in most cases reported in the literature, it is thought that early active and accurate biopsy with large-bore needles, or, if possible, surgical incision for early diagnosis and aggressive surgery to achieve complete resection combined with radiation therapy and/or chemotherapy would be very important for a good prognosis.

We report a 58-year-old male treated with surgical drainage by mediansternotomy using a pedicled omental flap for descending necrotizing mediastinitis (DNM). The patient recovered from DNM after five months of mechanical respiratory support. In deciding upon the most appropriate surgical approach for mediastinal drainage, the level of infection is a good landmark and should be investigated by CT scan. We also review the 43 cases of successful surgical treatment of DNM reported since 1989 in Japan, including our own patient, who were diagnosed with DNM by CT scan according to the classification proposed by Endo et al., and discuss the most appropriate surgical approach for mediastinitis based on the literature. In the treatment of DNM localized to the upper mediastinal space above the carina, a transcervical approach may be appropriate. In diffuse DNM extending into the lower anterior mediastinum, a mediansternotomy or a thoracotomy may be useful, and in diffuse DNM extending into both the anterior and posterior lower mediastinum, a thoracotomy may be the best approach for debridement of the lower posterior mediastinum, in addition to early complete debridement of the entire cervical area.

A 19-year-old woman with a history of drug addiction suffered from sepsis and heart failure. Blood culture was positive for Streptococcus viridans. An operation was indicated because the echocardiography showed massive vegetation on the anterior leaflet of the tricuspid valve and severe regurgitation even though the endocarditis was healed with drug therapy. At operation all of the anterior leaflet of the tricuspid valve was resected with the vegetation. Using the technique of cusp commissuroplasty, the disrupted commissure was reconstructed by approximating the septal and posterior cusps at the level of their normal closure, forming a zone of apposition by using a single stitch. Leaflet apposition resulted in a defect between the apposed leaflets and the tricuspid annulus, which was patched with autologous pericardium. The tricuspid valve was reconstructed to function as a unicommissural bicuspid valve. The patient was stable during the follow-up period of two years without any medical treatment.

We report a rare successful surgical repair of a common atrium (CA) with mild tricuspid valve (TV) regurgitation due to valvular annulus enlargement in a 39-year-old man, who had a complete atrial septum defect (ASD) without the characteristic of an endocardial cushion defect. The left-to-right shunt ratio was 85 percent and the Qp/Qs was 6.7 due to the CA. Left ventriculogram revealed no evidence of typical goose-neck deformity and no mitral valve regurgitation. The operation consisted of making a new atrial septum with an autologous pericardial patch and tricuspid annuloplasty (DeVega) using extracorporeal circulation. There was no evidence of a cleft on the anterior leaflet of the mitral valve or the septal leaflet of the TV. The postoperative echocardiogram showed no residual shunt flow through a new atrial septum and no TV regurgitation, and atrioventricular (AV) dissociation did not occur. We consider this procedure to be widely applicable in consideration of the favorable results obtained after surgical treatment.

A 53-year-old man crashed his motorcycle into a vehicle and was transported to our hospital by ambulance after about 30 min. Echocardiography revealed cardiac tamponade. Pericardiocentesis was immediately performed using a 5 Fr catheter via the subxiphoid approach and the results suggested cardiac injury. Surgery was commenced via median sternotomy about 2.5 hours after the accident. Patients with cardiac rupture who reach hospital alive can be saved by rapid transport, early detection, and early surgery. In particular, rapid echocardiography and pericardiocentesis via the subxiphoid approach under ultrasonic guidance are easy and helpful methods of making a diagnosis and achieving hemodynamic improvement prior to surgical intervention.

A 42-year-old man was admitted to another hospital complaining of acute abdominal pain that was induced by eating. Abdominal computed tomography and selective angiography revealed an intimal flap separating true and false lumens that was located 3 cm from the origin of the superior mesenteric artery (SMA). Emergency surgery was performed because of the sudden recurrence of diffuse abdominal pain after eating and abdominal aorta-SMA bypass grafting was done using a radial artery graft. Postoperative angiography revealed that the graft showed good patency. The postoperative course was uneventful and abdominal pain no longer occurred after eating. This excellent result was achieved by early diagnosis using CT scanning and angiography plus an aggressive surgical repair with a radial artery bypass graft for isolated dissection of the superior mesenteric artery.

Spontaneous and isolated dissection of the limb arteries without involvement of the aorta is extremely rare. We present a 36-year-old male who has 95% tapering stenosis and dissection of the left external iliac artery with abrupt onset with total thrombosis in the false lumen until the level of the inguinal ligament. We also suggest that endovascular stent graft placement is a useful treatment for isolated arterial dissections prior to operation in consideration of the technical ease and safety of guiding intravascular ultrasound like in this case.

A 48-year-old woman with an abnormal shadow in chest radiography during an annual physical examination was found by chest computed tomography to have a large fatty mass lesion found to be diagnosed as a gigantic lipoma. Histopathological diagnosis was found to be benign thymolipoma consisting of mature fatty tissue and hyperplastic thymic tissue structures with Hassall,s corpuscles. Although the diagnosis is supported by imaging studies that demonstrate fat and soft tissue within the tumor, variations occur in computed tomography appearance. We suggest that surgical excision be considered when a gigantic intrathoracic lipomatous mass is in scanning as in this case.

The thymus is an important organ involved in cell-mediated immunological function, and to our knowledge, there has never been a case of thymic metastasis reported. We recently examined a 65-year-old man who presented at our department with a cough and shortness of breath on exertion. He had a history of prostatic carcinoma for which he had undergone an orchiectomy 11 years previously. Investigations disclosed a mediastinal tumor, 14 x 9 cm in size, and histological examination of the resected tumor confirmed a diagnosis of thymic metastasis from prostatic carcinoma.

1987年4月から1992年3月までの5年間に広島大学第1外科で大動脈, 腸骨動脈領域の閉塞性動脈硬化症に対し人工血管バイパス術を施行した51症例を, 非解剖学的バイパス術を施行したEAB群18例と, 解剖学的バイパス術を施行したAB群33例に分け, retrospective に両群の比較を行った. 背景因子の検討では, EAB群の平均年齢はAB群よりも約10歳高齢で, 症状的には Fontaine 分類III, IV度の重症例が多く, 腎機能と肺機能もEAB群が劣っており, 脳梗塞等の合併症もEAB群で高かった. PGE-1製剤を術前術後にわたって長期間使用すること, 全身麻酔下に良好な視野を得て手術を行うこと, 末梢側病変に対しては全例同時血行再建手術を行うこと, externally supported external velour knitted Dacron 人工血管を使用すること等をルーチンに行っているが, 5年間に閉塞例を1例も認めていない. EAB群でもAB群に劣らない手術成績を得たので報告した.