Yoshihiko Katayama

Aorto-bronchial fistula after implantation of a self-expanding bronchial stent in a patient with aortic dissection.

We report a case of aorto-bronchial fistula after implantation of a self-expanding stent into the left main bronchus compressed by a dissected descending aorta. A 66-year-old female, who underwent Stanford type-B aortic dissection two years previously, was admitted to our hospital for the treatment of a newly developed false lumen that originated from the ascending aorta and extended to the aortic bifurcation. She was unable to be weaned from the respirator after the graft replacement of the ascending aorta. Fiberoptic bronchoscopic examination revealed complete obstruction of the left main bronchus by extrinsic compression. A self-expanding nitinol stent was implanted in the left main bronchus five days after the operation. Her respiratory condition improved remarkably, allowing her to be successfully weaned from the respirator. Her clinical course was uneventful until she suddenly died from massive hemoptysis 20 days after stent implantation. A communication of 5 mm in diameter between the dissected descending aorta and the left main bronchus was seen at autopsy. Permanent application of a self-expanding nitinol stent to relieve extrinsic compression of a left main bronchus by a dissected descending aorta is not recommended because pressure necrosis might lead to fatal aorto-bronchial fistula.

Bronchopulmonary foregut malformation.

Bronchopulmonary foregut malformation (BPFM) is a rare anomaly of accessory pulmonary tissue that usually arises from esophagus or stomach. We present a case of extralobar pulmonary sequestration (ELS) connecting with the esophagus by a cyst, the inner wall of which is lined with squamous epithelium or respiratory epithelium. BPFM is sometimes used to group a number of ventral anomalies of accessory pulmonary tissue. The term currently refers specifically to those lesions composed of sequestrations that retain communication with the gastrointestinal tract. Usually the communication is a well-formed muscular tube lined with stratified squamous or columnar epithelium. The presence of both epithelia in a communication that is a component of the BPFM suggests embryogenesis. We describe an adult with BPFM composed of ELS and a connecting stalk to the esophagus by a foregut cyst that contains both squamous epithelium and respiratory epithelium.

Subfascial Endoscopic Perforator Surgery Using Screw-Type Ports Is a Very Useful Component of a Comprehensive Treatment Program for Chronic Venous Insufficiency

BACKGROUND Subfascial endoscopic perforator surgery (SEPS) with a two-port system utilizing screw-type ports, CO2 insufflation and an ultrasonic coagulation system, is a useful procedure that does not require burdensome apparatus and techniques. SEPS was accepted as a national advanced medical system by the Japanese Ministry of Health, Labor and Welfare in May 2009. PATIENTS AND METHODS Forty-one limbs of 35 patients with 10 active ulcers (C6) and 2 healed ulcers (C5) were treated by SEPS between February 2010 and December 2011. Thirty-three limbs had concomitant superficial vein surgery. SEPS alone was performed on 8 limbs, in 6 of which the superficial veins had already been ablated. In 2 limbs, incompetent perforating veins (IPVs) existed under the affected skin, around the scars of past surgery. RESULTS All stasis ulcers of the 10 C6 limbs healed between 1 week and 14 months after SEPS (mean 2.9 months), with no ulcer recurrence during the follow-up period (2 to 24 months). IPVs under the scars were easily and safely interrupted by SEPS. CONCLUSION SEPS is a very useful component of a comprehensive treatment program for chronic venous insufficiency, especially in patients with venous stasis ulcers and IPVs under the scars of past surgery.

New application of a bipolar Nd:YAG handpiece in laser cardiac surgery

A bipolar Nd-YAG laser (1.064 micrometer) handpiece was experimentally examined for a venous dissection without scissors and sutures and clinically introduced for the vein graft harvesting in coronary artery bypass grafting (CABG). Experimental study: One hundred and thirty-five segments of the mongrel dog veins were employed. Nd-YAG laser was irradiated on the vein held by the bipolar Nd-YAG handpiece at the power of 5, 9, 13, and 17 watts, and success defined as a complete vein citing without bleeding at the laser-applied sites were gained in all except three; 97.8% of success rate. Laser exposure time for cutting the vein decreased in order to an increase of the applied laser power, and the veins of bigger diameter needed more longer exposure time in the group of the same laser power. An average exposure time was 4.4 seconds for the veins of 1 mm diameter at 13 watts. In histological examination, a vascular lumen at the cutting site was diminished and covered with a degenerated vascular wall, and bleeding was not seen in all specimen. Clinical study: In 18 cases of CABG the bipolar Nd-YAG handpiece was applied to cut the branches of the great saphenous vein without scissors and sutures. Forty-two grafts harvested by this handpiece were used for aortocoronary bypass grating. All were survived and the angiographic examination demonstrated a 90% of graft patency at an average period of 3.5 years after the operation. Laser-induced morphological change such as aneurysmal formation or graft stenosis was not recognized.

Subfascial endoscopic perforator surgery for posterolateral perforators performed in the prone position.

Objectives Subfascial endoscopic perforator surgery (SEPS) is usually performed for posteromedial perforators in the supine position, but subfascial endoscopic perforator surgery for posterolateral perforators in the prone position has not been reported. Methods A 51-year-old male suffered from a venous stasis ulcer around his lateral malleolus because of reflux in the small saphenous vein and incompetent perforating veins around the ulcer. Results Stripping of the small saphenous vein and subfascial endoscopic perforator surgery utilizing screw-type ports was successfully conducted in the prone position. Conclusions: The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space.

Surgical Treatment for Aortic Surgery Using Antegrade Selective Cerebral Perfusion

当施設で経験した脳分離体外循環使用症例は40例で,年齢45～79歳(平均67.2±8.1),男性29例,女性11例であった.40例のうち,緊急症例は21例(緊急群),待機症例は19例(待機群)で,緊急群,待機群につき比較・検討を行った.術式は,緊急群では,上行置換術15例,弓部全置換術5例,弓部部分置換術1例,待機群では,上行置換術2例,弓部全置換術17例で,待機群は,弓部全置換術が多かった.また,選択的脳灌流時間のみ有意差をもって待機群が長かった.在院死亡は,緊急群5例(23.8%),待機群1例(5.2%)で,脳神経障害に関しては,一過性の脳神経障害は,緊急群1例,待機群3例で,永続性の脳神経障害は,緊急群1例,待機群1例であった.われわれは,可能なかぎり体外循環の体送血を順行性とし,一貫して順行性選択的脳分離体外循環を用いてきたが,良好な成績であった.

A Case Report of Papillary Fibroelastoma of the Aortic Valve.

乳頭状弾性線維腫は原発性心臓腫瘍のうち3番目に多いとされているが, 全心臓腫瘍中8%で, 頻度的には非常に希である. 今回われわれは大動脈弁より発生した乳頭状弾性線維腫の1手術例を経験した. 症例は51歳の女性で検診にて心電図異常を指摘されて当院を受診し, 心エコー検査にて大動脈弁の右冠尖に有茎性腫瘍を認め, 大動脈弁腫瘍と診断された. 腫瘍はゼリー状であり, 大動脈弁の接合状態は良好で機能不全をきたしていなかったので, 腫瘍のみを切除した. 病理組織学的には乳頭状弾性線維腫と診断された.