2016年 · 第32卷第06期

Female, 44 years old. Persistent burning pain in left chest and back 3 months ago. Physical examination: heart rate 80 beats/min, breathing 20 beats/min, blood pressure 150/78 mmHg (1 mmHg =0.133 kPa) in right upper limb, 130/65 mmHg in left upper limb and 110/57 mmHg in lower limb. A rough murmur of grade 2~3/VI in systolic phase could be heard in the intercostal area of 3~4 on the left margin of sternum. Cerebral vascular MRI enhanced scan showed intact willi ring of the brain. Echocardiography showed no obvious abnormalities in the morphology and structure of the heart, and abnormal echoic areas on the posterolateral side of the left anterior pericardial cavity of the main pulmonary artery (considering true aneurysm). CTA showed that the left cervical aortic arch (CAA) was accompanied by huge aneurysm formation, about 6.8 cm ×6.4 cm in size, the opening of the tumor involved the descending aorta and the left subclavian artery, and the proximal lumen of the left subclavian artery was thickened (Figure 1)。 X-ray chest radiograph showed left superior mediastinum occupying space (Figure 2)。

Male, 1 year 4 months, 12 kg. Physical examination found cardiac murmur for 1 year. Echocardiographic diagnosis of "congenital heart disease, tetralogy of Fallot, atrial septal defect". 64-slice CT showed "aortic riding, ventricular septal defect, atrial septal defect, right ventricular hypertrophy, right ventricular outflow tract and pulmonary artery stenosis". In August 2014, he underwent "tetralogy of Fallot correction and atrial septal defect repair" under general anesthesia and cardiopulmonary bypass. Intraoperative transvalvular autologous pericardial patch enlarged the right ventricular outflow tract to the left pulmonary artery.

From April 2013 to July 2014, a total of 114 patients with aortic dissection (AD) were admitted for surgical treatment, and 5 patients without deep hypothermic circulatory arrest were excluded. A total of 109 patients were included in this study. There were 89 males and 20 females; The age ranged from 22 to 71 years, with a mean (49.03 ± 12.06) years. For other basic information, seeTable 1。 There were 96 cases of acute aneurysms (onset ≤14 days) and 13 cases of chronic aneurysms. Emergency surgery (admission to operation time ≤48 h) was performed in 50 cases and non-emergency surgery in 59 cases. The surgical methods included ascending aorta + arch replacement + descending aortic stent implantation in 61 cases, David + arch replacement + descending aortic stent implantation in 13 cases, Bentall + arch replacement + descending aortic stent implantation in 13 cases, sinoplasty + ascending aorta + arch replacement + descending aortic stent implantation in 10 cases, ascending aorta + arch replacement in 11 cases, and arch replacement + descending aortic stent implantation in 1 case.

The effect of single-port thoracoscopy is the same as that of multi-port thoracoscopy, and it can further reduce chest wall trauma, intraoperative bleeding, and reduce postoperative pain and surgical scar^[1]。 We have been performing single-port total laparoscopic lobectomy since January 2013 and have achieved good clinical results. The summary report is as follows.

In order to avoid incision contamination during thoracoscopic surgery, the excised specimens should be placed in the specimen bag and removed. At present, there are commercialized pickup bags, which are expensive. Domestic thoracic surgeons often use sterile gloves instead, but the common problem of such substitutes is that the opening is not supported by hard objects, and it is difficult to put the specimen into the bag. Especially with the reduction of the number of incisions and the reduction of the length of the incision, this situation is more obvious. The repeated movement of the cut specimen in the chest cavity may increase the probability of adverse events. We changed sterile gloves to self-made glove sample bags, and the clinical application effect is good. The summary report is as follows.

The incidence of spontaneous esophageal rupture is low, but its misdiagnosis rate and mortality rate are high. The most common complications are severe mediastinal and thoracic infections, and severe failure caused by rapid consumption^[1]。 Patients whose time from onset to diagnosis was less than 24 hours had good results after one-stage surgical repair^[2,3,4]。 In our department, patients with late spontaneous esophageal rupture were treated with pedicled diaphragmatic flap for primary repair surgery, and good results were achieved, which are reported below.

Female, 58 years old. In 2009, due to rheumatic heart disease, moderate to severe mitral valve stenosis, moderate aortic valve stenosis with a small amount of regurgitation, small amount of tricuspid valve regurgitation, pulmonary valve thickening, and mild stenosis, he underwent Carbomedics bilobar mechanical valve replacement of mitral and aortic valves under general anesthesia and cardiopulmonary bypass, and suture plasty of anterior tricuspid septum junction. Pulmonary valve stenosis (PS) was mild, and no special treatment was done during operation. The operation was successful, with oral warfarin anticoagulation and monitoring of the international standardized ratio (INR) of about 2.0. There was no discomfort in the early postoperative period, and echocardiography revealed normal mechanical valve function and normal left ventricular systolic function.

Female, 37 years old, weight 58 kg. Shortness of breath after exercise for nearly 2 years, aggravated with back pain for 5 days. CT of pulmonary artery showed thrombosis in the main trunk of pulmonary artery and the initiation of the right trunk of pulmonary artery. Laboratory test: white blood cells 14.75×10⁹/L, D-dimer 740 μ g/L. Echocardiography showed chronic pulmonary thrombosis. Pulmonary artery CTA showed embolism of the main pulmonary artery and right pulmonary artery (Figure 1)。 In order to exclude pulmonary artery tumors, PET/CT examination was performed. No metabolic images of solid malignant tumors were found, and pulmonary artery thrombosis was considered. Reexamination D-dimer: 5 390 μ g/L. Preoperative diagnosis of chronic pulmonary thromboembolism (CPTE).

postpneumonectomy syndrome (PPS) is a rare long-term complication after pneumonectomy^[1]。 For such complications, conservative treatment is almost ineffective and usually requires surgical treatment. Recently, we successfully treated a case of post-pneumonectomy syndrome with metal bronchial stent placement, which is now reported below.

Female, 12 years old. In infants and young children, the symptoms of cough and yellow purulent sputum appear repeatedly, which are obviously aggravated after seasonal changes or respiratory tract infections every year. Symptoms worsened with hemoptysis in June 2015. Physical examination: apical beat was seen on the right chest wall, and the boundary of cloudy sound was right heart. The blood routine, biochemical indexes and blood coagulation were all normal. However, chest CT showed a triangular-like consolidation shadow in the middle lobe of the left lung, with the tip pointing laterally and the bottom edge close to the mediastinum, and an inflatable bronchial shadow was visible inside it (Figure 1)； B-ultrasound of abdominal cavity showed visceral inversion, and no abnormal blood flow signal was found; Pulmonary function showed FVC 2.68 L, FEV1 2.29 L and MVV 49.53 L/min, accounting for 70.1% of the predicted values. The diagnosis was mirror dextrocardiac, complete visceral transposition and left middle lobe syndrome. After 2 weeks of anti-infectious treatment, the chest CT examination showed that there was no improvement in the left middle lobe lesions. Then in July 2015, a single operating hole thoracoscopic left middle lobectomy was performed under general anesthesia and double-lumen tracheal intubation. During the operation, the left lung developed into three lobes, the middle lobe shrank and consolidated, and membranous and band-like adhesions were seen with the mediastinal pleura and the upper and lower lobes (Figure 2), the operation went smoothly. Postoperative pathological diagnosis: (left) lung dysplasia with middle lobe syndrome (Figure 3)。 The patient recovered well after operation and was cured and discharged on the 5th day.

Case 1A male, 18 years old. Height 165 cm, weight 45 kg. Three months before admission, we underwent video assisted thoracic surgery (VATS) in an external hospital due to right pneumothorax. Two bullae with a diameter of 20 mm in the apical segment of the right upper lung were resected and closed with endoscopic cutting and suturing device and pleural fixation. Three days before this admission, the chest X-ray in the external hospital showed left pneumothorax (Figure 1Left), the lung compression was about 50%, the symptoms were relieved after oxygen inhalation, and the symptoms appeared again 3 days later. The chest radiograph still showed the left lung compression of 40% and was admitted to our hospital. Physical examination showed no abnormalities in thoracic appearance, and left lung auscultation breathing sounds were weakened. VATS operation was performed in August 2013. One bulla with a diameter of 5 mm in the apical segment of the left upper lung was seen during the operation, and it was resected by endoscopic linear cutting and suturing device.