Tatsuhiko Nishii

Surgery for Ruptured Abdominal Aortic Aneurysm with an Aortocaval and Iliac Vein Fistula

The purpose of this study was evaluate the operative procedure and outcome of abdominal aortic aneurysm (AAA) patients with aortocaval fistula (ACF) and iliac vein fistula. From 1982 through 2004, we experienced five AAA patients associated with spontaneous aortocaval and aortoiliac venous fistula who underwent repair of AAA. Three patients were in hypovolemic shock, including one patient with cardiopulmonary arrest on admission who required cardiopulmonary resuscitation before surgery. These three ACF patients with hypovolemic shock underwent emergency operation and two patients with stable hemodynamic state underwent urgent operation. One of two ACF patients with stable condition was associated with unstable angina. One AAA patient with ACF-complicated angina underwent AAA repair with coronary artery bypass grafting; the remaining four patients underwent 3 bifurcated graft and 1 tube graft implantation. All surgical treatment of the fistula included direct closure within the aorta under digital compression in four patients and inferior vena cava clamp in one. The mortality rate was 25%. One ACF patient with retroperitoneal hematoma died of bleeding. Survival for ACF depends on early diagnosis and prompt surgical repair. Aortocaval fistula complicated with a rupture of aneurysm into retroperitoneal space had a severe fatal prognosis compared with uncomplicated ACF.

Preventing recurrence of spontaneous pneumothorax after thoracoscopic surgery: A review of recent results

Spontaneous pneumothorax (SP) is now commonly treated with thoracoscopic surgery, which is associated with less pain and a shorter hospital stay than thoracotomy; however, in its initial stages, thoracoscopic stapled bullectomy resulted in an unexpectedly high incidence of postoperative SP recurrence. Thus, new thoracoscopic procedures, designed to be performed in addition to stapled bullectomy, were developed, which resulted in a gradual decline in the postoperative recurrence rate. We review the recent literature on SP recurrence after thoracoscopic surgery with these other surgical procedures. Pleurectomy and pleural abrasion have been performed for a long time with low recurrence rates; however, they cause the lung to adhere to the parietal pleura, often resulting in complications such as postoperative bleeding. Other surgical procedures that may be recommended to minimize the risk of recurrence are reinforcement of the staple lines using fleece-coated glue or an absorbable sheet. These procedures are now considered to be the thoracoscopic treatment of choice for SP.

Mature Cystic Teratoma With Malignant Transformation to Adenocarcinoma

An anterior mediastinal tumor had been found in a 65-year-old woman 10 years previously, and she had been followed-up under the diagnosis of a mature cystic teratoma. Changes in the structure of the inside of the mediastinal cystic tumor were observed on a chest computed tomography image, and she was referred to our hospital for surgical intervention. The tumor was removed and was determined to be a mature teratoma. An adenocarcinoma was also observed in part of this cystic lesion. From these findings, the lesion was diagnosed as a malignant change in a mediastinal mature teratoma. Because few if any changes tend to be observed in the cystic wall of such cases, an aggressive resection of such mature cystic teratomas is therefore recommended.

Pulmonary Langerhans Cell Histiocytosis With Recurrent Pneumothorax

A 20-year-old woman with recurrent right pneumothorax was admitted to our hospital. A thoracoscopic bullectomy and lung biopsy was performed under general anesthesia. According to the histopathologic findings of permanent sections, a tissue specimen of diffuse lung disease revealed eosinophil infiltration and the presence of fibroblasts. Immunohistochemical stain showed S-100 protein-positive, as well as cluster of differentiation-68-positive large Langerhans cells. As a result, pulmonary Langerhans cell histiocytosis was diagnosed. The patient had an uncomplicated postoperative course and was discharged from the hospital on postoperative day 5. No recurrence was observed during the 6-month observation period.

Cause and Management of Recurrent Primary Spontaneous Pneumothorax After Thoracoscopic Stapler Blebectomy

BACKGROUND As the number of patients treated by thoracoscopic stapler blebectomy increased, the postoperative recurrence rate had risen unexpectedly. We retrospectively investigated the cause and management of primary spontaneous pneumothorax recurrence after thoracoscopic stapler blebectomy. METHODS From March 1992 to the end of December 2006, thoracoscopic stapler blebectomy was performed in 357 patients with primary spontaneous pneumothorax at the Nihon University Itabashi Hospital. The causes and management of recurrence were investigated in 30 patients with postoperative recurrence based on items such as the resurgical observations, preoperative chest computed tomography findings, previous operative notes. RESULTS Among the patients with bilateral pneumothorax, young patients exhibited a higher tendency for postoperative recurrence. The most common cause was new bulla formation (28 slides, 16 of which were apparently related to the staple line and 12 of which were not related to the staple line). CONCLUSION In thoracoscopic stapler blebectomy for primary spontaneous pneumothorax, the most common cause of recurrence was new bulla formation. It is necessary to establish additional procedures involving either the visceral pleura or the parietal pleura to reduce the recurrence rate.

Surgical Treatment of Catamenial Pneumothorax

OBJECTIVE To discuss the aetiology and determine the optimal surgical treatment of catamenial pneumothorax. METHODS Between January 1980 and December 2007, 17 patients with catamenial pneumothorax were treated at our institution. Regarding the surgical approach, thoracotomy was performed until 1991, and thoracoscopic surgery was performed from 1992 onward. RESULTS Pneumothorax was on the right side in all but two patients. Surgery was performed on 15 of the 17 patients. The surgical procedure was a diaphragm resection plus a partial bleb resection in eight patients, a diaphragm resection in two patients, a diaphragm resection plus an absorbable polyglycolic acid sheet in four patients, and a partial bleb resection in one patient. Five patients demonstrated a postoperative recurrence (33.0%). However, no recurrence has been observed thus far in the four patients with an absorbable polyglycolic sheet placed on the diaphragmatic surface. CONCLUSION Although the postoperative recurrence rate of patients undergoing surgical procedures remains high, there were some patients with no postoperative recurrence. Placement of an absorbable sheet on the diaphragmatic surface may therefore prevent recurrence of catamenial pneumothorax.

Study of Thoracic Egg for spontaneous pneumothorax

自然気胸に対し，近年，簡易型胸腔ドレナージキット（ソラシックエッグ®）を挿入し，外来経過観察となる症例が増加している．今回，ソラシックエッグ®の有用性の有無を検討した．対象は過去2年間，当科外来でのソラシックエッグ®挿入46症例．ソラシックエッグ®挿入前の肺虚脱度は軽度から中等度虚脱43症例，高度虚脱3症例．予定手術12症例を除く非予定手術34症例のうち外来観察のみで軽快したのは21症例（61.8％）．膨張不良による入院となったのは13症例（38.2％）であり，このうち12症例（35.3％）に気漏遷延のため手術が必要であった．これらの平均外来観察期間は8.6日であった．一方，予定手術12症例では平均在院日数が8.25日で当科における入院期間の短縮が得られた．ソラシックエッグ®は軽度から中等度虚脱症例に対し有用であり，外来観察期間は7～9日間が限界で，以降の観察期間で膨張不良である場合，入院による治療が必要であると考える．

Evaluation of Catheter-Directed Thrombolysis for Acute Deep Vein Thrombosis

近年,急性期深部静脈血栓症に対するカテーテル血栓溶解療法(CDT)や血栓吸引療法を含めた血管内治療の有効性が報告されている.今回,2003年1月より2004年8月までに当科で経験した深部静脈血栓症のうち,血管内治療を行った20例について検討した.血管内治療の適応は,発症から2週間以内,腸骨大腿静脈血栓閉塞型の深部静脈血栓症を対象とした.内訳は男性11例,女性9例,平均年齢56.4(30～78)歳,発症からの治療開始までの期間は平均4.4(1～12)日であった.血栓存在部位は左側15例,右側5例であり,血栓が存在する最も中枢側の静脈は下大静脈5例,腸骨13例,大腿2例であった.一時型下大静脈フィルターを留置したのちに,膝窩静脈よりシース挿入,カテーテルは多孔式を用い,ウロキナーゼは24万単位を1日量としてdrip infusion法と1日3～5回のpulse-spray法を併用とした.抗凝固療法はヘパリンを使用し,また,間欠的マッサージ(IPC)で患肢血流うっ滞を予防した.再造影にて血栓が残存する場合には機械的血栓吸引療法を施行し,iliac vein compression syndrome (IVCS)や器質化血栓に対しては金属ステントを留置した.治療前後の静脈造影にてvenographic severity score(VSスコア)と四肢周囲径にて治療効果判定とした.治療期間は5.0±0.28(2～9)日,総ウロキナーゼ使用量は102.5±5.7(36～168)万単位であった.総腸骨静脈にIVCSで1例,器質化血栓に対して2例に金属ステントを留置した.治療中2例に一時下大静脈フィルター内に血栓を捕捉したことが確認されたが,肺塞栓症は認めなかった.血栓性素因は2例に認められ,1例に抗リン脂質抗体症候群,もう1例にプロテインS欠乏症がみられた.早期再発を1例に認め,再度血管内治療を要した.VSスコアは術前26.2±6.3から治療後6.2±2.5と有意に(p<0.0001)低下した.急性期深部静脈血栓症に対して血管内治療は有効であり,満足しうる結果であると思われた.