Kiyoshi Doi

Blunt cardiac injury due to trauma associated with snowboarding: a case report

BackgroundCardiac trauma is associated with a much higher mortality rate than injuries to other organ systems, even though cardiac trauma is identified in less than 10% of all trauma admissions. Here we report blunt trauma of the left atrium due to snowboarding trauma.Case presentationA 45-year-old Asian man collided with a tree while he was snowboarding and drinking. He lost consciousness temporarily. An air ambulance was requested and he was transported to an advanced critical care center. On arrival, a pericardial effusion was detected by a focused assessment with sonography for trauma. His presenting electrocardiogram revealed normal sinus rhythm and complete right bundle branch block. Laboratory findings included a white blood cell count of 13.5u2009×u2009103/μl, serum creatine kinase level of 459xa0IU/l, and creatine kinase–myocardial band level of 185xa0IU/l.Enhanced computed tomography showed a large pericardial effusion and bleeding from his left adrenal gland. There were no pelvic fractures. A diagnosis of cardiac tamponade due to blunt cardiac injury and left adrenal injury due to blunt trauma was made. Subsequently, emergency thoracic surgery and transcatheter arterial embolization of his left adrenal artery were performed simultaneously. A laceration of the left atrial appendage in the lateral wall of his left ventricle was detected intraoperatively and repaired. His postoperative course progressed favorably, although a pericardial effusion was still detected on chest computed tomography on hospital day 35. His electrocardiogram showed normal sinus rhythm and the complete right bundle branch block pattern changed to a narrow QRS wave pattern. He was discharged on hospital day 40.ConclusionsThe present case report illustrates two points: (1) severe injuries resulted from snowboarding, and (2) complete right bundle branch block was caused by blunt cardiac injury. The present report showed blunt trauma of the left atrium with complete right bundle branch block as an electrocardiogram change due to snowboarding trauma. To detect cardiac trauma in snowboarding accidents, an examination of an electrocardiogram is required in all patients who might have a bruised chest.

Coronary Artery Bypass Grafting for an Anomalous Left Coronary Artery from the Pulmonary Artery in a 73-Year-Old Female.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) in adults is a rare congenital coronary abnormality. We report a case of ALCAPA in a 73‐year‐old female managed by total arterial revascularization. doi: 10.1111/jocs.12755 (J Card Surg 2016;31:380–382)

Radical resection of a giant retroperitoneal calcifying fibrous tumor combined with right hepatectomy and reconstruction of the inferior vena cava and bilateral renal veins

BackgroundWe report a case of a giant retroperitoneal calcifying fibrous tumor (CFT) treated by radical tumor resection combined with right hepatectomy and reconstruction of the inferior vena cava (IVC) and bilateral renal veins. Only three case reports of CFT arising in the retroperitoneum have been reported until today.Case presentationIn a 19-year-old female patient, computed tomography (CT) images showed a well-demarcated expansile lesion around the IVC accompanied by focal calcification, whereas the IVC that was circumferentially surrounded by the lesion was dilated due to the desmoplastic reaction. On magnetic resonance imaging (MRI), the lesion demonstrated heterogeneous hypointensity on T2-weighted images. Delayed enhancement was observed on dynamic contrast-enhanced CT and MRI. 18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT images showed increased FDG uptake [maximum standardized uptake values (SUVmax), early image 7.28; delayed image 7.40]. On operative examination, because the tumor adhered to the liver parenchyma, the right Glisson capsule, and the origin of bilateral renal veins, radical tumor resection combined with right hepatectomy and reconstruction of the IVC and bilateral renal veins was performed.ConclusionsRadical tumor resection was successfully and appropriately performed for a young patient with a giant retroperitoneal CFT with a view to achieving complete venous reconstruction and safe surgical margins for a potentially malignant tumor.

Thoracoscopic segmentectomy: hybrid approach for clinical stage I non-small cell lung cancer

BackgroundnRecently, minimally invasive surgical approaches have been developed, typified by video-assisted thoracic surgery (VATS). A meticulous surgical procedure to prevent local recurrence is required during segmentectomy for clinical stage I non-small-cell primary lung cancer. In this article, we demonstrated the validity of hybrid VATS segmentectomy.nnnMethodsnOf these 125 patients, 62 (49.6%) underwent intensively radical segmentectomy (RS). The remaining 63 (50.4%) patients underwent palliative segmentectomy (PS). We used two 2-cm ports and performed a muscle-sparing mini-thoracotomy in which a partially open metal retractor allowed direct, thoracoscopic visualization as hybrid VATS segmentectomy in 63.2% of our cases.nnnResultsnThe consolidation/tumor ratio obtained with thin-sliced computed tomography was significantly lower in RS cases than in PS cases (P=0.001). The proportion of pathological stage IA cases was significantly higher in RS cases (95.2%) than in PS cases (66.7%; P<0.01). Five-year overall survival (OS) for clinical stage I was 100.0% in RS cases and 73.5% in PS cases (log-rank P<0.001). Five-year disease-free survival (DFS) was 95.5% and 55.7%, respectively (log-rank P<0.001).nnnConclusionsnDuring segmentectomy, the most critical consideration is establishment of sufficient surgical margins around the cancer. Our hybrid approach that includes meticulous surgical manipulations may produce sufficient surgical margins.

Division of the intersegmental plane using electrocautery for segmentectomy in clinical stage I non-small cell lung cancer

BackgroundnDivision of intersegmental planes is one of the important practical issues for segmentectomy to obtain feasible outcomes without relapse for clinical stage I non-small cell lung cancer. Almost all surgeons perform this procedure using a stapler. However, division of intersegmental planes for segmentectomy can also be performed by electrocautery. In this article, we demonstrate the merits and drawbacks of division of the intersegmental plane by electrocautery for segmentectomy.nnnMethodsnOf those 125 patients who underwent segmentectomy with clinical stage I primary lung cancer, we compared cautery cases (n=50) with stapler cases (n=75). The cautery group included 29 cases (58.0%) with partial use of a staple at the end of division.nnnResultsnOperative time was significantly longer in cautery cases (281±72 min) than stapler in cases (235±86 min; P=0.003). No difference in the duration of chest tube placement was evident between cautery (3.0±3.0 days) and stapler groups (2.8±1.7 days; P=0.613). However, delayed air leakage occurred significantly more frequently in cautery cases (14.0%) than in stapler cases (4.0%; P=0.048). Five-year overall survival (OS) in clinical stage I was 94.7% in cautery cases and 80.5% in stapler cases (log-rank P=0.047). Five-year disease-free survival (DFS) was 80.0% and 71.3%, respectively (log-rank P=0.075).nnnConclusionsnThe merits of cautery division include the ability to achieve meticulous division of the intersegmental plane and good preservation of the shape of residual segments. Conversely, the drawbacks include prolonged air leakage. Pleural suture or closure of residual segments may be useful to prevent delayed air leakage.

Suppression of aortic expansion and contractile recovery in a rat abdominal aortic aneurysm model by biodegradable gelatin hydrogel sheet incorporating basic fibroblast growth factor

Biodegradable gelatin hydrogel sheet (BGHS) incorporating basic fibroblast growth factor (bFGF) may inhibit the progression of abdominal aortic aneurysm (AAA). We investigated whether AAA in a rat model treated with BGHS soaked with bFGF can suppress aortic expansion and recover the contractile response of aneurysmal aortic wall. Experimental AAA was induced in 10-week-old male Sprague–Dawley rats with intra-aortic elastase infusion. Aortas of these rats were assigned to 4 groups (nxa0=xa06 each) as follows: Control group, aortas infused with saline; Elastase only group, aortas infused with elastase; Hydrogel group, aortas wrapped with saline-soaked BGHS after elastase infusion; and bFGF group, aortas wrapped with bFGF (100xa0μg)-soaked BGHS after elastase infusion. Preoperatively and on postoperative day (POD)7 and POD14, mean aortic maximal diameter was measured ultrasonographically. Aortic expansion ratio was calculated as: (post-infusion aortic diameter on POD14/pre-infusion aortic diameterxa0×xa0100). Aortas were stained with Elastica van Gieson and α-smooth muscle actin to measure the ratio of elastic fibers and α-smooth muscle actin-positive cells area to the media area. Aortas on POD14 were cut into 2-mm rings and treated with contractile agent, then tension was recorded using myography. Maximum aorta diameters were significantly greater in Elastase only group, Hydrogel group, and bFGF group than in Control group (on POD14). Maximum diameter was significantly lower in bFGF group (3.52xa0±xa00.4xa0mm) than in Elastase only group (6.21xa0±xa01.4xa0mm on POD14, Pxa0<xa0.05). On histological analysis, ratio of the area staining positively for elastic fibers was significantly greater in bFGF group (7.43xa0±xa01.8%) than in Elastase only group (3.76xa0±xa02.9%, Pxa0<xa0.05). The ratio for α-smooth muscle actin-positive cells was significantly lower in Elastase only group (38.3xa0±xa05.1%) than in Control group (49.8xa0±xa06.7%, Pxa0<xa0.05). No significant differences were seen between Elastase only group and bFGF group, but ratios tended to be increased in bFGF group. Consecutive mean contractile tensions were significantly higher in bFGF group than in Elastase only group. Maximum contractile tension was significantly higher in bFGF group (1.3xa0±xa00.4xa0mN) than in Elastase only group (0.4xa0±xa00.2xa0mN, Pxa0<xa0.05). Aortic expansion can be suppressed and contractile responses of aneurysmal aortic wall recovered using BGHS incorporating bFGF.

Hybrid approach for VATS pulmonary resection

Many different surgical VATS procedures are performed. In our thoracoscopic VATS, four ports are used with thoracoscopic vision alone. In our hybrid VATS, two 2-cm ports are combined with muscle-sparing mini-thoracotomy with a slightly opened metal retractor with direct vision and thoracoscopic vision. Both procedures are performed by an operator, one assistant, and a scopist. Forceps, electrocautery, and ultrasonic scissors were used. VATS segmentectomy is an ideal surgical procedure to treat primary lung cancer from the perspective of minimally invasive surgery. The most important issue in segmentectomy is to maintain a sufficient surgical margin from the tumor. We think that it is important to determine whether thoracoscopic VATS segmentectomy without direct visualization or rib spreading can achieve an adequate surgical tumor-free margin. Delicate surgery is required to keep the surgical margin in segmentectomy. Therefore, the hybrid approach seems to be reasonable for obtaining sufficient surgical margins.