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The Japanese Journal of Thoracic Surgery Volume 74, Issue 4 （April 2021）

胸部外科 74巻4号（2021年4月発行）

Japanese English

特集弓部大動脈瘤―いかに合併症をなくすか

弓部大動脈全置換術の標準化とその成績―術者の経験値は手術成績に影響を与えるか？ Does Surgeons’ Experience Affect the Surgical Outcomes of Total Arch Replacement? 大村篤史 ¹ , 井上大志 ¹ , 濵口真理 ¹ , 村上優 ¹ , 長命俊也 ¹ , 河野敦則 ¹ , 松尾二郎 ¹ , 辻本貴紀 ¹ , 幸田陽次郎 ¹ , 山中勝弘 ¹ , 井上武 ¹ , 岡田健次 ¹ Atsushi Omura ¹ , Taishi Inoue ¹ , Mari Hamaguchi ¹ , Yu Murakami ¹ , Shunya Chomei ¹ , Atsunori Kono ¹ , Jiro Matsuo ¹ , Takanori Tsujimoto ¹ , Yojiro Koda ¹ , Katsuhiro Yamanaka ¹ , Takeshi Inoue ¹ , Kenji Okada ¹ ¹神戸大学心臓血管外科 ¹Department of Cardiovascular Surgery, Kobe University キーワード：弓部大動脈全置換術 , 胸部大動脈瘤 , 経験値 Keyword: total arch replacement , thoracic aortic aneurysm , experience pp.297-303

発行日 2021年4月1日 Published Date 2021/4/1

DOI https://doi.org/10.15106/j_kyobu74_297

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参考文献 Reference

弓部大動脈置換術は，脳保護の進歩，手術手技の向上，人工血管の改良などにより，手術成績が大きく改善した．最新の本邦の全国集計によると，非解離性大動脈疾患に対する待機手術の病院死亡率は3.0％と報告されている1）．しかし，低体温循環停止を要する侵襲度が高い手術の一つであることにかわりなく，いったん重篤な合併症が発症すれば，患者の生命のみならず生活の質（QOL）も大きく損なわれる可能性がある．われわれは，術者の技量に大きく依存せず，安全かつ合併症を許容範囲内に収めるために，弓部全置換術の標準化に努めてきた2，3）．当院の弓部全置換術における注意点と，執刀医の経験値が手術成績にどのような影響を与えるかについて検討を行った．

Objectives：Total arch replacement （TAR） is used to be a complicated and quite invasive aortic procedure. To perform TAR safely and effectively under all circumstances, we have constructed standardization of the procedures of TAR. The aim of this study is to analyze the impact of surgeons’ experience on surgical outcome of TAR to evaluate our standardization.

Methods：From January 2008 to December 2020, 346 consecutive patients （mean age 73.6±10.2） underwent elective TAR through a median sternotomy at our institute. TAR was performed by three types of surgeon classified by their experience （A：over 20 years, B：15～20 years, C：under 15 years）. The surgical outcomes were examined. Our standard approach include （1） meticulous selection of arterial cannulation site and type of arterial cannula；（2） antegrade selective cerebral perfusion；（3） maintenance of minimal tympanic temperature between 20 ℃ and 23 ℃；（4） early rewarming just after distal anastomosis；（5） maintaining fluid balance below 1,000 ml during cardiopulmonary bypass.

Results：The operative cases were 227 in A, 86 in B and 33 in C. Surgeon A operated more complicated TAR with higher operative risk compared with B and C. The hospital mortality and major complication rate was not significant difference among surgeons （hospital mortality A：3.5％, B：2.3％, C：3.0％）. Multivariate analysis showed the surgeons’ experience was not associated with hospital mortality and major complications. Long-term outcomes were also compatible among three groups.

Conclusions：Our standardization for TAR seemed to be an useful approach to eliminate the impact of surgeon experience on surgical outcomes if the type of surgeon was appropriately selected according to the level of operative difficulty.