[Zasshi] [Journal]. Nihon Kyobu Geka Gakkai最新文献

From July 1988 through August 1996, 54 patients with chronic renal failure (CRF) on maintenance dialysis (50 hemodialysis = HD, and 4 continuous ambulatory peritoneal dialysis) have undergone some sort of surgical procedure requiring the use of extra corporeal circulation (ECC); 42 patients underwent isolated coronary artery bypass grafting (CABG), 8 valve replacement, 3 combined procedures and 1 correction of a congenital heart defect. The protocol called for maintenance dialysis on the day before surgery, large volume hemofiltration (HF) during the ECC period, postoperative K+ management with dextrose-insulin if required, and resumption of whatever preoperative maintenance dialysis 24 hours after the operative procedure. The mean diafiltrate volume of HF was 7963 +/- 2688 ml which was replaced with 6342 +/- 2748 ml. No patient required emergency HD before the resumption of the maintenance dialysis, although in 40% of the early patients HD was added on the second postoperative day. However as experience was gained, in the latter 60% of patients resumption of maintenance dialysis (HD 3 times a week) was thought to be sufficient. The incidence of calcification in patients with CRF is higher not only of involved coronary artery segments (4.5 +/- 2.3 segments; AHA coronary classification) than its counterpart without CRF, but also of the ascending aorta which mandated modifications of the technique in 6 patients (operation under ventricular fibrillation, cannulation access other than ascending aorta). The use of arterial in situ conduits for CABG was also thought to be advantageous, and the left internal thoracic artery combined to the gastro-epiploic artery was used in 11 patients (26.2%). Four patients died) (7.4%): 2 from arrhythmia, one from intestinal necrosis and one from multiple cerebral infarction. Thus we conclude that the outlined protocol is quite effective in controlling fluid and electrolyte balance in patients on maintenance dialysis allowing to undertake surgical procedures requiring the use of extra corporeal circulation relatively safely.

A case of non-Hodgkin malignant lymphoma of the lung was presented with a review of Japanese literatures. A 53-year-old woman was referred to our hospital because of an abnormal shadow on the roentgenogram of mass screening, with neither subjective symptoms nor abnormalities in physical examinations. Laboratory tests showed normal values. The diagnosis of pulmonary malignant lymphoma was obtained by immunohistochemical examinations. She underwent a upper lobectomy of the left lung with lymph nodes dissection of the mediastinum. The histological immunohistochemical and diagnosis of the resected tumor was primary pulmonary B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) without regional lymph nodes involvement. She has been doing well without any signs of recurrence for 15 months after the operation.

Surgical management of patients with concomitant resectable lung lesions and critical cardiac disease is controversial. We report a case of concomitant pulmonary and cardiac surgery via a left thoracotomy. A 67-year-old male was admitted to our hospital complaining of recurrent bloody sputum and an abnormal shadow on chest X-ray. Chest CT and MRI showed a tumor in the left lower lobe (S10), with invasion of the diaphragm. A diagnosis of squamous cell carcinoma was obtained by transbronchial lung biopsy. The patient had a history of angina pectoris, and stress testing was positive. Coronary angiography showed 90% stenosis at segment 5, suggesting a risk of perioperative or postoperative myocardial infarction. This necessitated simultaneous surgical treatment for lung cancer and ischemic heart disease. A lobectomy of the left lower lung was performed, followed by coronary artery bypass grafting (CABG), using the great saphenous vein. The postoperative course was uneventful except for the occurrence of cholecystitis. Lung cancer and ischemic heart disease can be safely treated simultaneously via a single incision, with and benefit for selected patients.

We report a surgical case of aorto-pulmonary septal defect (APSD) in a neonate weighing 1693 gm. A male twin baby delivered after 39 weeks and 5 days of gestational period was diagnosed as APSD. RAA, PFO and PLSVC by a echocardiography and a MRI. Because of the progressive cardiac failure, operation was performed under cardiopulmonary bypass and profound hypothermic circulatory arrest at 30 days of age and weighing 1693 gm. APSD was closed completely by a Dacron patch. Postoperative course was almost uneventful except for pulmonary hypertension crisis. He recovered without brain damage.

The reconstruction of LV cavity is accomplished by suturing a patch to the viable myocardium to exclude the infarcted area from the high LV pressures. However, there is no clear guideline to estimate the size of patch used for LV reconstruction. We have designed a new method to determine the correct patch size, and applied it in 5 cases. The suture line of the patch is at the junction of contractile (functional) and infarcted portions of LV. The patch size is determined by the length of AB, termed "a", as the base, where "point A" represents the junction on the LV anterior wall side, and "point B" the junction of the LV posterior wall side, from RAO 30 degrees projection of the left ventriculogram obtained by cardiac catheterization. In LV aneurysm, we designed the patch in the range of a/2 < l < or = pi a/2, where patch length on RAO 30 degrees is considered "l". An effort was made to reconstruct to normalize LV volume and contour by designing the patch size to be a/2 < l < a, particularly when the contractile portion was enlarged by aneurysm. On the other hand, in post AMI VSD, LV contractile portion is not enlarged in early stage. Therefore, the patch was designed in the range of a < l < or = pi a/2 to maintain LV volume. Postoperative LV volume can be calculated prior to surgery, by using the lengths of the designed patch. Postoperative analysis indicated that the actual LV volume and contour were almost identical to our estimation. This method is very useful in planning the patch size for LV reconstruction.

A 53-year-old male was admitted with cough and chest pain. A chest X-ray film showed left pleural effusion and a chest CT revealed irregular thickening of the pleura. Pleural fluid cytology and percutaneous needle biopsy were negative for malignancy. Thoracoscopic findings revealed fibrin network with pleural effusions and yellow-white pleural thickening, but neither nodules nor masses were found. The thoracoscopic biopsy specimen from the pleural thickening resulted in the diagnosis of malignant pleural mesothelioma. Left pleuropneumonectomy with mediastinal lymph node dissection was performed. Since detailed inspection of the pleural cavity and taking large biopsy samples under thoracoscopic examination are possible, we consider thoracoscopic biopsy to be a useful method for obtaining diagnosis of malignant pleural mesothelioma. Pleuropneumonectomy and systematic lymph node dissection of the pulmonary hilum and mediastinum were believed to be necessary for the surgical treatments.

Twenty years after making an arteriovenous shunt in the left arm, a 45-year-old man on hemodialysis developed progressive swelling in the face to left arm and venous dilatation on the left anterior chest. Venogram disclosed severe stenosis of the left innominate vein at the junction of the superior vena cava, which was considered to be a primary lesion because he had no history of subclavian vein cannulation or mediastinal disease. Surgical resection of the stenotic lesion and direct anastomosis of the innominate vein resulted in a rapid recovery of the symptom of venous hypertension. This is a rare case of hemodialysis-associated large vein complication leading to superior vena cava syndrome.

A 4-year-old girl with tetoralogy of Fallot developed acute heart failure after ASD semiclosure. As drugs had no effect, ECLS was instituted. She gradually recovered from acute heart failure. ECLS was detached at 5 days after institution. Neutrocytopenia and lymphocytopenia became apparent during ECLS institution. The Subpopulations of T cell and NK cell decreased, and B cell subpopulation increased on the contrary during ECLS institution. This lymphocytopenia was caused by a decrease in T cell, especially CD4(+) cell numbers. It is necessary to minimize the potential for infection during ELCS institution.

We reported two male and one female patient (17, 36 and 47 years old, respectively) who presented infectious endocarditis (IE) in association with ventricular septal defect (VSD). In all cases, surgical treatment was performed in the acute stage of IE for persistent sepsis, pulmonary embolisms, and for giant vegetations. Because the tricuspid valve apparatus was severely damaged, valve replacement with the Carpentier-Edwards pericardial bioprosthesis was done and small VSD was directly closed in all cases. In one case, a complete heart block occurred, which necessitated postoperative implantation of a permanent pacemaker. All patients recovered and resumed their original social activities without the relapse of endocarditis.

A 63-year-old man was brought to our hospital 20 minutes after sustaining blunt injury. He had been struck by a steel frame weighing about 700 kg that had fallen from a height of 2 meters. On admission, he was in cardiogenic shock with a systolic pressure of 70 mmHg and a pulse rate of 130 beats/minute. There was no apparent open wound and no brain injury was suspected. Echocardiography and chest computed tomogram showed cardiac tamponade, and abdominal computed tomogram showed liver injury. We performed emergency operation under cardio-pulmonary bypass standby. Laceration of the inferior vena cava at the right atrium junction was noticed. We had to perform IVC repair under cardio-pulmonary bypass because of massive bleeding. Liver injury was repaired after neutralization of systemic heparinazation. The patient developed respiratory, hepatic and renal failure during his postoperative course; however, he was discharged on postoperative day 39. Intrapericardial IVC injury caused by blunt trauma is a very rare event. Reconstruction can be performed successfully under cardio-pulmonary bypass.