Yoshinobu Hattori

Urgent surgical repairs were successfully performed in four patients with blunt traumatic ruptures of the thoracic aorta. All 4 patients were involved in traffic accidents and had ruptures immediately distal to the aortic isthmus. The diagnoses were achieved by IV-DSA in case 1, by IV-DSA and enhanced CT in case 2 and by enhanced helical CT in cases 3 and 4. Intraoperative transesophageal echocardiography was performed in case 4. Operations were accomplished with the aid of temporary shunt in case 1, pulmonary-femoral artery bypass in case 2 and partial left heart bypass in cases 3 and 4. Prosthetic graft interposition was performed in cases 1, 3 and 4 and end-to-end aortic anastomosis was performed in case 2. There was no postoperative paraplegia in any patient. Early diagnosis and urgent surgical repair are important in treating blunt traumatic rupture of the thoracic aorta. Enhanced helical CT and transesophageal echocardiography are useful for the diagnosis of this type of injury.

Hemangioma is one of the most uncommon tumors in the mediastinum. We experienced a 12-year-old girl who had a mediastinal mass shadow on screening chest X-ray examination. Physical examination revealed no abnormal findings. Routine blood examinations were all within normal limits. Plain chest X-ray film showed a mass shadow in the left upper mediastinum. Plain chest CT scans showed that homogeneous-density tumor developed from the left thymus toward the anterior portion of aortic arch. Left internal thoracic arteriograms showed pooling and cotton wool like staining with contrast medium in the tumor. The tumor was completely resected through a median sternotomy on Dec. 13, 1984. Histological examination showed that the tumor was a benign cavernous hemangioma extending to surrounding fatty tissue, which suggested the possibility of future recurrence. Thirteen years follow up at the outpatient clinic, however, has shown no evidence of recurrence so far.

Urgent surgical repairs were successfully performed in four patients with blunt traumatic ruptures of the thoracic aorta. All 4 patients were involved in traffic accidents and had ruptures immediately distal to the aortic isthmus. The diagnoses were achieved by IV-DSA in case 1, by IV-DSA and enhanced CT in case 2 and by enhanced helical CT in cases 3 and 4. Intraoperative transesophageal echocardiography was performed in case 4. Operations were accomplished with the aid of temporary shunt in case 1, pulmonary-femoral artery bypass in case 2 and partial left heart bypass in cases 3 and 4. Prosthetic graft interposition was performed in cases 1, 3 and 4 and end-to-end aortic anastomosis was performed in case 2. There was no postoperative paraplegia in any patient. Early diagnosis and urgent surgical repair are important in treating blunt traumatic rupture of the thoracic aorta. Enhanced helical CT and transesophageal echocardiography are useful for the diagnosis of this type of injury.

Hemangioma is one of the most uncommon tumors in the mediastinum. We experienced a 12-year-old girl who had a mediastinal mass shadow on screening chest X-ray examination. Physical examination revealed no abnormal findings. Routine blood examinations were all within normal limits. Plain chest X-ray film showed a mass shadow in the left upper mediastinum. Plain chest CT scans showed that homogeneous-density tumor developed from the left thymus toward the anterior portion of aortic arch. Left internal thoracic arteriograms showed pooling and cotton wool like staining with contrast medium in the tumor. The tumor was completely resected through a median sternotomy on Dec. 13, 1984. Histological examination showed that the tumor was a benign cavernous hemangioma extending to surrounding fatty tissue, which suggested the possibility of future recurrence. Thirteen years follow up at the outpatient clinic, however, has shown no evidence of recurrence so far.

Primary tracheal carcinoma is rare. A 58-year-old man had hemoptysis in early March, 1997 and was treated for a polypoid vocal cord by an otorhinolaryngologist. When he was admitted to another hospital on Aug. 23 because of a traffic accident, he expectorated bloody sputum, a cytological examination of which revealed class 111 cells. He was referred to our hospital for more examinations on Sep. 6. Bronchoscopy demonstrated a polypoid tumor in the trachea and a biopsy revealed squamous cell carcinoma. There was no metastasis. Tracheal resection from the 4th to 8th tracheal ring and end-to-end anastomosis was performed on Oct. 21. Pathological examination demonstrated a moderately differentiated squamous cell carcinoma in situ and immunohistochemical examination and in situ hybridization showed positive stainings. A relationship with human papillomavirus was strongly suspected. The postoperative course was uneventful.

Cardiac fibromas are rare tumors. A 12-year-old girl who had no cardiac symptoms was evaluated because of her abnormal ECG. Physical examination revealed a grade 1/6 systolic murmur. Routine laboratory examination results and the chest X-ray films were normal. The ECG showed a negative T wave at leads II, III, aVF and V_3-4. Two-dimensional echocardiography demonstrated a tumor in the lower right ventricular free wall. Operation was performed on July 12, 1990. Sharp dissection was used to remove the tumor through right ventriculotomy. She had an uneventful postoperative course and is well 7 years later with no evidence of recurrence. Pathological findings including immunohistochemical studies revealed cardiac fibroma. The 22 reported cases of cardiac fibroma in Japan were reviewed.

Four patients with abnormal chest roentgenograms were evaluated and were proven intralobar pulmonary sequestration (IPS) at surgery. A 7-year-old boy and a 26-year old man had left lower IPS. Helical 3D-CT demonstrated the aberrant artery arising from the descending thoracic aorta and the draining pulmonary veins. They underwent left lower lobectomy. A 23-year-old man and a 35-year-old woman had right lower IPS. Helical 3D-CT demonstrated the aberrant artery arising from the abdominal aorta and the draining pulmonary veins. They were treated by left lower partial lobectomy. Helical 3D-CT is noninvasive, and provides accurate, three-dimensional information of the aberrant vascular supply of the pulmonary sequestration, which closely simulates the angiographic and surgical findings. Helical 3D-CT can replace angiography in the preoperative diagnosis of the pulmonary sequestration.

A 68-year-old woman underwent left upper lobectomy on September 25, 1990 because of primary left upper lobe lung cancer. The resected specimen demonstrated well differentiated adenocarcinoma and pathological stage I (pT1N0M0). Adjuvant chemotherapy (VP-16, CDDP) performed. Dyspnea appeared around July 1991. Chest CT and bronchofiberscopy revealed stenosis the left main bronchus but no tumor recurrence. A chest X-ray film on February 22, 1994 showed an abnormal shadow in the left upper lung field. Chest CT demonstrated a tumor in the left S^6 and the result of CT-guided needle biopsy suggested metastasis. She had no, distant metastasis. Left completion pneumonectomy was performed on April 26, 1994. Clockwise torsion of the left main bronchus around the longitudinal axis at an angle of 90° was found. Histological study dernonstrated two recurrent lung cancers. Postoperatively, she had no dyspnea and her performance status was Hugh-Jones grade 2. She died of systernic metastasis 3 years and 7 months after the left completion pneumonectomy.

A 51-year-old man was referred for evaluation of an abnormal upper mediastinal shadow on routine chest roentgenogram. Laboratory data including thyroid hormone, parathyroid hormone and tumor markers were normal except liver function. CT and MRI showed a 3-cm cystic mass attached to the right side of the trachea. Axillo-anterior thoracotomy was performed and the mass was removed. Parathyroid hormone content in the serous fluid within the cyst was 24000 pg/mKouseikai Takai Hospital. Histopathologic examination revealed a parathyroid cyst, and the tumor was diagnosed as a nonfunctioning parathyroid cyst.

Cardiac fibromas are rare tumors. A 12-year-old girl who had no cardiac symptoms was evaluated because of her abnormal ECG. Physical examination revealed a grade 1/6 systolic murmur. Routine laboratory examination results and the chest X-ray films were normal. The ECG showed a negative T wave at leads II, III, aVF and V_3-4. Two-dimensional echocardiography demonstrated a tumor in the lower right ventricular free wall. Operation was performed on July 12, 1990. Sharp dissection was used to remove the tumor through right ventriculotomy. She had an uneventful postoperative course and is well 7 years later with no evidence of recurrence. Pathological findings including immunohistochemical studies revealed cardiac fibroma. The 22 reported cases of cardiac fibroma in Japan were reviewed.

Four patients with abnormal chest roentgenograms were evaluated and were proven intralobar pulmonary sequestration (IPS) at surgery. A 7-year-old boy and a 26-year old man had left lower IPS. Helical 3D-CT demonstrated the aberrant artery arising from the descending thoracic aorta and the draining pulmonary veins. They underwent left lower lobectomy. A 23-year-old man and a 35-year-old woman had right lower IPS. Helical 3D-CT demonstrated the aberrant artery arising from the abdominal aorta and the draining pulmonary veins. They were treated by left lower partial lobectomy. Helical 3D-CT is noninvasive, and provides accurate, three-dimensional information of the aberrant vascular supply of the pulmonary sequestration, which closely simulates the angiographic and surgical findings. Helical 3D-CT can replace angiography in the preoperative diagnosis of the pulmonary sequestration.

A 51-year-old man was referred for evaluation of an abnormal upper mediastinal shadow on routine chest roentgenogram. Laboratory data including thyroid hormone, parathyroid hormone and tumor markers were normal except liver function. CT and MRI showed a 3-cm cystic mass attached to the right side of the trachea. Axillo-anterior thoracotomy was performed and the mass was removed. Parathyroid hormone content in the serous fluid within the cyst was 24000 pg/mKouseikai Takai Hospital. Histopathologic examination revealed a parathyroid cyst, and the tumor was diagnosed as a nonfunctioning parathyroid cyst.

Clinical performances were compared of MAXIMA (M), Sarns 16310 (S), and MERA-EXCELUNGα(E) on 81 patients who underwent open-heart surgery at our institution be-tween January 1989 and June 1990. There were 29 patients for MAXIMA, 36 patients for Sarns, and 16 patients for Excelungα. The age, body weight, total priming volume, dilution factor, and extracorporeal circulation time were, 54 years 55kg, 2030ml, 20% 168min, for MAXIMA group; 24 years, 30kg, 1487ml, 23%, and 137min for Sarns group; and, 44 years, 55kg, 1911ml, 21%, and 153min for Excelung group. Age, body weight and total priming volume were significantly smaller for S-group but otherwise there was no statistically significant difference. Oxygen concentration was set at 70% at the start of cardiopulmonary bypass and then adjusted if necessary. All of three groups had satisfactory oxygenation, but 2.4% of PaO₂ measurements with S- and E-groups showed values below 200mmHg, whereas all values for Mgroup were above 200mmHg. The ratio between gas flow (V) and pump flow (Q) (V/Q) was 0.19 for M-group, 0.37 for S-group, and 0.32 for E-group. PaCO₂ values were 31mmHg for M-group, 32mmHg for S-group, and 28mmHg for E-group; thus CO₂ clearance of M-group was better than S-group, and S-group was inferior to E-group. The V/Q ratio needed to be doubled in all three groups during the rewarming phase, but nevertheless PaCO₂ during this phase was higher than that during the cooling phase.

Between January 1986 and July 1989, cardiopulmonary bypass without blood priming was attempted in 55 patients, During the course of hospitalization no blood transfusion was used in five of seven patients with the body weight under 20kg, in nine of 11 patients weighing between 20 and 30kg, and in 30 out of 37 patients weighing more than 30kg. With proper case selection, open heart surgery without blood transfusion was possible even in patients weighing less than 20kg.