シンカ スル ウシン バイパス ジュンカン

Since Fontan’s exploit over 30 years ago, a number of important advances relevant tothe Fontan strategy could be achieved as being variations in the technique of anatomical connectionof the systemic venous circulation to the pulmonary arteries and variations instaging of the Fontan procedure. Innovative Norwood procedure and its concept as a firststage of palliation to Fontan circulation have been equivalent to Fontan’s exploit, and haveproduced the “current” philosophy of pushing patients into Fontan physiology early in lifewith hemi-Fontan procedure or bidirectional Glenn shunt.The aim of the first half of our present study is to determine the optimal size and techniquefor construction of the systemic-to-pulmonary arterial shunt which will provide suitablepulmonary blood flow in first-stage Norwood palliation for hypoplastic left heart syndromein neonates. A prosthesis of 3.0 or 3.5 mm in diameter arising from the brachiocephalicartery would be acceptable and can be recommended for first-stage Norwood palliation insmall infants. Although many complicated factors are concerned in the regulation of pulmonaryblood flow, the fundamental strategy is to create a necessary and minimal systemicto-pulmonary arterial shunt in the first-stage Norwood palliation, and then to proceed swiftlywith a second-stage hemi-Fontan procedure.It remains to be determined whether all children should undergo an intermediate hemi-Fontan procedure or bidirectional Glenn shunt prior to their Fontan completion. In my personalopinion, the several advantages of the hemi-Fontan procedure seem to be weighed againstits disadvantages. It is our current practice to perform an intermediate hemi-Fontanprocedure in staging of the Fontan strategy of the patients with some risk factors. Althoughwe generally have waited 6-8 months after a hemi-Fontan operation for a Fontancompletion, we would like to perform an early Fontan completion a few months after hemi-Fontan procedure to shorten the period of partial Fontan circulation and get nearly normaloxygen saturation. Careful follow-up and further investigation will be necessary to determinethe most optimal management guidelines for the Fontan circulation

Intimal sarcoma from the iliac artery

We present a rare case of intimal sarcoma arising from the common iliac artery in an 82-year-old man who presented with intermittent claudication. He had undergone endovascular therapy with self-expanding stents to both iliac arteries that had occluded soon after placement. After salvage bypass grafting, a diagnosis of intimal sarcoma with angiosarcoma phenotype from the iliac artery was made. Further bypass graft surgery relieved symptoms temporarily. However, the tumor progressed and the left limb became ischemic. The chemotherapy of eribulin did not prevent tumor progression. The patient died of the disease 20 months after the first surgery

Efficacy and Optimal Timing of TEVAR for Type B-AD

Objectives: To determine the efficacy and the optimal timing of thoracic endovascular aortic repair (TEVAR) for closing the primary entry in uncomplicated patients with chronic type B aortic dissection and a patent false lumen (FL). Methods: Thirteen patients underwent TEVAR for aortic dissection between 2008 and 2012. These patients had chronic dissection with a patent FL and expansion of the aorta. Early TEVAR was performed for five patients within 1–7 months from the index dissection (TEVAR-EC group) and delayed TEVAR was performed for eight patients within 1–16 years (TEVAR-DC group). Changes in the diameters and volumes of the true lumen (TL) and FL and the aortic remodeling were assessed by multidetector computed tomography for 3 years after TEVAR. Results: The reduction rate of FL in the thoracic aorta was notably higher in the TEVAR-EC group than in the TEVAR-DC group regardless of the presence or absence of distal retrograde flow. There was a significant TL expansion despite different timings of TEVAR. Conclusions: Early TEVAR resulted in good prognosis and preferable aortic remodeling in uncomplicated patients with chronic type B aortic dissection and a patent FL, and we recommend early TEVAR within seven months after the index dissection

フエツズケル ダイドウミャクリュウ チリョウ : カイキョウ カイフク シュジュツカ ステント グラフト チリョウカ

The treatment of Aortic aneurythm is shifting stent graft treatment from open Surgery. Stent graft treatment is useful for the treatment of thoracic aortic aneurythm if the form is adaptable for the stent graft treatment. Open surgery is useful for the treatment of abdominal aortic aneurythm if the patient have no complication and high operative lisk but if the patint have complication and high operative lisk, Stent graft treatment is very useful because of the quality of life is kep

チアノーゼ性心疾患に対する肺動脈絞扼術

The early and late results of pulmonary artery banding (PAB) for cyanotic heart defects in early infancy were reviewed. Nine patients were divided into two groups : Group F (five patiens) in which Fontan type repairs were expected as definitive repair in the near future ; Group A (four patients) in which anatomical repairs were programmed in the near future. Six patients had a good early postoperative course, and then consisted of three patients of Group A and three patients of Group F. The band circumference, intraoperative pulmonary-to-systemic systolic pressure ratio and arterial oxygen tension after PAB in the good cases of Group A were 20.0±1.7 mm + 1 mm for each kilogram of the infant's weight, 0.52±0.07 and 46.4±11.3 mmHg respectively. These indices in the good cases of Group F were 21.1±1.7 mm + 1 mm for each kilogram of the infant's weight, 0.55±0.02 and 38.8±1.0 mmHg respectively. The standard deviations of every index for PAB in Group F were small. Three patients of Group A have undergone successful total correction. Intraoperative pulmonary-to-systemic systolic pressure ratio of 0.5 as the index of PAB is preferable to Group A. However, only two patient of Group F were waiting for Fontan type definitive repair. For the patient especially in Group F, careful observation and well-timed staged repair with regard to subaortic stenosis and restrictive atrial septal defect and ventricular septal defect are necessary after accurate PAB as mentioned above

Surgical management of infants with mitral valve stenosis or atresia without diminutive ascending aorta

The surgical strategy in infants with mitral valve stenosis or atresia without diminutive ascending aorta remains to be established, including the potential for biventricular repair as a definitive operation. Our surgical experience of six infants with mitral valve stenosis (4patients) or atresia (2patients) without diminutive ascending aorta was evaluated based on three important factors:left ventricular volume;the nature of the systemic outflow obstruction; and the type of mitral valve anomaly. Two patients with systemic outflow tract diameter less than 65% of normal underwent systemic outflow tract reconstruction, and the other patients with outflow tract diameter more than 68%of normal were able to maintain systemic circulation without repair. Only one patient with mitral valve stenosis without left ventricular outflow tract obstruction underwent a successful open mitral valvotomy as a biventricular repair after first-stage palliation. The left ventricle of the other patients did not grow after first-stage palliation. Due to progressive subaortic narrowing, pulmonary artery banding should be avoided in patients with mitral atresia due to absent atrioventricular connection who are future Fontan candidates. Most patients with this lesion can be expected to become candidates for safe Fontan-type repair

フクマク ハシュ オ トモナッタ コウド シンコウ イガン ニ タイスル TS 1 ニヨル ジュツゼン カガク リョウホウ ノ ユウヨウセイ

TS -１ is an oral anticancer agent developed by utilizing biochemical modulation. We used TS -１in neoadjuvant chemotherapy for a patient with highly advanced gastric cancer that was accompanied by peritoneal dissemination. This enabled us to resect tumor. This patient was a６０-year-old woman. Fluoroscopic upper gastrointestinal series revealed a circumferential, type４lesion extending from the middle of the corpus to the antrum. This was diagnosed by endoscopy as poorly differentiated adenocarcinoma. CT showed ascites, thickening of the gastric wall, and direct infiltration into the head of the pancreas. In endoscopy of the large bowel, a strawberry jelly-like elevation was detected at the ileum. This was diagnosed as poorly differentiated adenocarcinoma, and considered a metastatic lesion produced by dissemination. Chest CT showed a single metastasis in the upper lobe of the right lung. We gave her３cycles of combined TS-１and low-dose CDDP for neoadjuvant chemotherapy. On laparotomy, we found that there was no ascites, and miliary scars were present at several sites near the ascending colon. The antrum of the stomach firmly adhered to the head of the pancreas, and scarred. We judged that the tumor was resectable, and performed distal gastrectomy（D２）plus ileocecal resection（D２）． In histopathological examination, poorly differentiated adenocarcinoma was detected only on a part of the muscular layer in the lesser curvature and posterior wall of the corpus, and marked fibrosis was observed in the submucosal layer. The effect of chemotherapy was histologically evaluated as grade２. The tumor was diagnosed as poorly differentiated adenocarcinoma（por）, with muscularis propria（mp）, lymph invasion２（ly２），vein invasion ０（v０）and degree of lymph node metastasis２（+）［n２（+）］. Tubular adenocarcinoma was detected in a part of the submucosal layer of the ileum. The patient was alive with cancer as of２７months after operation

チョメイナ ノウホウ ケイセイ オ トモナッタ カンサイボウ ガン ノ 1ジケンレイ

It is said that in hepatocellular carcinoma, necrosis is liable to occur in the center and the percentage of cystic formation is comparatively low, but as we have experienced one case of hepatocellular carcinoma associated with marked cystic formation, we reported it. The patient was a female aged７０years. Because general fatigue and anorexia occurred, Abdominal CT test was conducted and hepatic mass was pointed out. Contrast-CT test showed a tumor of６cm in diameter in the medial segment of the left lobe of the liver. As the border was stained with arterial phase, the center was not imaged and the tumor was diagnosed as vascular proliferating type hepatic tumor associated with marked cystic change. MRI test showed that the border of the tumor was lobular and part thereof was of septal structure. The tumor was diagnosed as hepatocellular carcinoma associated with bleeding in tumor, hepatic cystadenocarcinoma or hepatic sarcoma. Abdominal angiography showed not only marked vascular proliferation and tumor stain in the area of the middle hepatic artery but also early venous return, and the middle hepatic vein was clearly imaged. The tumor size was ５×５×４cm in size and was in contact with the middle hepatic vein but it did not invade the vein. Left hepatic lobectomy was performed. Histopathologically the center of the tumor was cystic with colliquative necrosis. The tumor had the trabecular structure and the tumor cell was consisted of clear cell. The tumor was thus diagnosed as poorly differentiated hepatocellular carcinoma. Postoperative course was good and the patient was discharged from our hospital on the１９th day after operation. At the moment when１９ months have passed since the operation, the patient is alive without any recurrence of carcinoma