[Thoracoscopic pleural biopsy under local anesthesia using a 2 mm laparoscope].

Thoracoscopy is indicated in patients with undiagnosed effusion after conventional methods. It has been usually performed under general anesthesia or using a thoracoscope with a thoracoscope with a diameter over 5 mm. However, it is an invasive diagnostic technique. We evaluated the feasibility of thoracoscopic pleural biopsy under local anesthesia using a 2 mm laparoscope. Six patients with a pleural effusion of unknown etiology after conventional methods, underwent thoracoscopy under local anesthesia. A 2 mm laparoscope and biopsy forceps (2 mm Minisite, United States Surgical Corp., USA) was used in all patients. Pleural fluid was removed, and the thoracic cavity was inspected. Thoracoscopic intercostal blocks were performed with 1% lidocaine, and then a biopsy was performed. The biopsy specimen was sent for histopathology. Three patients were shown to have carcinomatous pleurisy, two of them with localized lesions less than 10 mm. In the remaining three patients, non-specific diagnoses were made, but long-term follow-up revealed no malignant pleural disease. Although the pictures obtained using a 2 mm laparoscope were inferior in quality, they were adequate for the detection of malignant lesions in the pleural cavity. There were no procedure-related complications. These findings suggest that thoracoscopy using a 2 mm laparoscope is (1) a useful diagnostic tool in cases of pleural malignancy; (2) a minimally invasive method with the advantage of being easily performed under local anesthesia. Thus, thoracoscopic pleural biopsy using a 2 mm laparoscope appears to be useful for undiagnosed pleural effusion.

Endobronchial stenting as a palliation for advanced esophageal cancer.

Three cases of airway invasion of esophageal cancer treated palliatively by endobronchial stenting are reported. In case 1 (a 60-year-old male) expandable metallic stents were inserted into the totally occluded left main bronchus. In case 2 (a 45-year-old male) a Dumon stent was inserted into the totally occluded left main bronchus. Both patients recovered from performance status 4 to performance status 1 or 0 and were in good condition before they died of cancer, 150 and 54 days after stenting in cases 1 and 2, respectively. In case 3, a Dumon stent was inserted into the left main bronchus before total occlusion. The patient recovered from performance status 3 or 2 to performance status 1 or 0 and survived 40 days after stenting with no signs of airway obstruction. Endobronchial stenting is a useful palliation for keeping the performance status at a good level in patients with esophageal cancer obstructing or narrowing the main airway.

Management of malignant tracheobronchial stenosis with metal stents and Dumon stents.

BACKGROUND: Tracheobronchial stenosis caused by malignancy is a life- threatening problem. Stenting is one of the treatment modalities and recently has been used widely for the management of such stenosis, but we do not have a clear guide as to which stent should be selected. METHODS: We evaluated 25 patients (19 men, 6 women; mean age, 60.7 years; range, 34 to 77 years) received 24 metal stents (four covered with silicone rubber) and three Dumon stents. All 25 patients had severe dyspnea because of airway stenosis caused by malignant tumors. RESULTS: Among the 25 patients, airway obstruction due to extrinsic compression by tumor developed in 11 and was treated with a bare metal stent. The airway remained patent in 10 patients. In 16 patients with intraluminal tumor invasion, nine lesions were treated with a bare metal stent, four lesions with a covered metal stent, and the remaining three lesions with a Dumon stent. Recurrent stenosis did not occur in any patient with a covered metal stent or a Dumon stent. However, restenosis occurred in 4 patients with a bare metal stent, all of whom received laser therapy. In all patients, stenting immediately relieved dyspnea. Six patients lived for 32 days to 53 months after stenting, and 19 patients died of primary malignancies with a mean survival of 131.9 days. CONCLUSIONS: Metal stents are effective in treating malignant extrinsic tracheobronchial compression. The use of covered metal stents or Dumon stents is preferable for intraluminal stenosis due to malignant growth.

[A case of mucoepidermoid carcinoma of the thymus].

A 19-year-old man was admitted to our hospital with anterior mediastinal cystic tumor. Subtotal thymectomy with the tumor was performed. The tumor was localized inside the thymus without outer infiltration. It weighed 145 g and measured 9 x 8 x 5 cm. The cut surface was cystic and spongy, partially with a solid focus. Pathological findings of the solid area was compatible with mucoepidermoid carcinoma of the thymus. The histogenesis of mucoepidermoid carcinoma of the thymus was discussed.

[A case of desmoplastic malignant mesothelioma].

A 43-year-old man was admitted to Nara Medical University Hospital because of right-sided chest pain. Computed tomographic examination revealed a right pleural effusion and diffuse pleural thickening. Malignant mesothelioma was diagnosed from the results of a percutaneous pleural biopsy, and the patient then underwent right pleuro-pneumonectomy. The resected specimen was examined by light and electron microscopy, which revealed scattered sarcoma-like malignant cells with some epithelial differentiation, in abundant extracellular collagen with storiform derangement. Therefore, desmoplastic malignant mesothelioma (mixed type) was diagnosed. This is a rare histological subgroup of malignant mesotheliomas. The patient died 2 months after the operation, due to multiple and rapidly growing metastases. After lung tissue was dissolved, ferruginous (asbestos) bodies were counted, and the results were consistent with occupational exposure to asbestos (413 asbestos bodies per 5 g of lung tissue).

Flow cytometric analysis of the DNA content of thymomas.

In this study, the prognostic value of determining the nuclear DNA content of thymomas by flow cytometry was evaluated. Of a total 31 resected thymomas, 10 (32%) showed DNA aneuploidy, the presence of which was significantly correlated with an advanced clinical stage of disease. The patients with an aneuploid tumor had a poorer prognosis than those with a diploid tumor, demonstrating a survival rate of 50% at 7 postoperative years, which was considerably less favorable than that of the patients with a diploid tumor, being 100% in the same period (p < 0.05). Moreover, patients with a high DNA index (DI), i.e., a DI >or= 1.5, tended to have a poorer prognosis than those with a low DI. These findings indicated that the DNA content can be an important prognostic index in patients with thymomas.

[The relationship between postoperative changes of exercise capacity and pulmonary blood flow in the residual lung after lobectomy of the lung].

The purpose of this study is to investigate a relationship between the postoperative change of exercise capacity judged by the change of peal oxygen consumption and the pulmonary blood flow of the residual lung after lobectomy. Twenty eight patients undergoing lobectomy for lung cancer received an exercise tolerance test and 99mTc-MAA perfusion lung scans before and after lobectomy. The change rate in the peak level of oxygen consumption (peak VO2) did not differ depending on the number of resected sub-segments. A good correlation was found between the reduction of perfusion ratio of the lung of the operated side (delta Q) and that of the peak level of oxygen consumption (delta peak VO2) (r = 0.74, p < 0.01). A reduction in delta Q and delta peak VO2 was remarkable in patients with postoperative respiratory complications such as atelectasis and pulmonary air leakage. These results indicate that the perfusion lung scans at rest before and after surgery would be able to predict the change of exercise capacity after lobectomy.

[Comparison of various methods to close the stump of the main bronchus after pneumonectomy].

In 58 patients who underwent pneumonectomy, the stumps of the main bronchus were sutured manually (by the Sweet method in 13, the Overholt method in 12, and the modified Overholt method in 8) or with machines (TA-30 + S method in 15, TA-30 + O method in 10), and the methods to close the stump were evaluated according to the outcome and postoperative endoscopic findings. Cancer was positive at the stump in 3, and rupture of the membranous portion was observed in 1 in the mechanical suture group. Bronchial fistula was observed in 2 (12%) of the 25 patients in the mechanical suture group but in none of the 33 patients in the manual suture group. The line of closure of the bronchial stump observed by endoscopy was perpendicular to the crest at the tracheal bifurcation in patients sutured by the Sweet or TA-30 + S method, angulated in a chevron shape in many of those sutured by the Overholt method and those sutured by TA-30 + O method, and parallel to the crest in part of those sutured by Overholt method and those sutured by modified Overholt method. The mucosa at the stump was uneven in many patients who showed chevron shaped closure lines. By the modified Overholt method, the wall of the main bronchus could be resected more extensively, the mucosa at the stump was smooth, and the airway lumen showed no marked deformation.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of eosinophilic pneumonia with histologically proven mediastinal lymph node involvement].

Intrathoracic lymphadenopathy in eosinophilic pneumonia is very rare and few cases have been confirmed histologically. This is the first case of eosinophilic pneumonia with mediastinoscopic lymph node biopsy reported in Japan. The case is a 42-year-old man who was admitted to our hospital complaining of cough, general fatigue and dyspnea of one month's duration. Chest X-ray demonstrated bilateral hilar and mediastinal lymph node enlargement with interlobar pleural thickening and infiltrative shadows in right lower lung field. Computed tomography revealed infiltrative shadows at right S4, S5, S8 and S9 and S10 segments and #2, #3, #5, #6 lymph node enlargement. Biopsy of the lymph node via mediastinoscopy demonstrated that the architecture was preserved, sinusoids were filled with histiocytes and eosinophils, and lymphoid follicles were compressed. Immunohistochemical technique using monoclonal antibody EG2 which reacts with the secreted form of Eosinophilic Cationic Protein (ECP), demonstrated that eosinophils infiltrating the mediastinal lymph nodes were activated. The pathogenesis of mediastinal lymphadenopathy in eosinophilic pneumonia remains to be determined, but our case suggests that mediastinal lymph nodes may play a role in eosinophilic pneumonia.

Incomplete interlobar fissures: bronchovascular analysis with CT.

Thin-section computed tomographic scans of both lungs in 154 patients, including seven cadavers, with lung cancer (n = 37), diffuse (n = 32) or inflammatory (n = 30) lung disease, other proved or suspected disease (n = 23), or healthy lungs (n = 32) were analyzed to determine the frequency of incomplete interlobar fissure (IIF). An IIF was defined as a discontinuous linear shadow that remained in contact with the chest wall. An IIF was found in 128 of 154 right lungs (83.1%) and 77 of 154 left lungs (50.0%). Some bronchovascular structures crossed or passed through two contiguous lobes in the fused area. The most common bronchovascular structure associated with an IIF was a pulmonary vein; this association was found in 87 right lungs (56.5%) and 20 left lungs (13.0%). An IIF was traversed by a pulmonary artery in only seven right lungs and 13 left lungs or by a bronchus in only three lungs. It is concluded that recognition of an IIF might improve understanding of the spread of pulmonary disease.

[Successful surgical management for chronic sternal osteomyelitis and anterior mediastinal abscess after double valve replacement by total sternectomy and pectoralis major muscle flaps].

A 63-year-old woman underwent double (aortic and mitral) valve replacement in February, 1987. Thirty days later, purulent drainage developed at the sternotomy incision with high fever. Wound cultures revealed staphylococcus aureus. She was treated by local wound care with antibiotics. About one month later, she had a satisfactory wound healing. But three cutaneous fistulas with discharge emerged at the sternotomy incision in November (9 months later) and the cultures grew the same species. The fistulogram showed the communication between these tracts and the mediastinum. The diagnosis of chronic sternal osteomyelitis and anterior mediastinal abscess was made. At first the resection of the xiphoid process and the mediastinal drainage were carried out in March, 1988. Inspite of this procedure, she still had persistent purulent discharge. Then, en bloc excision of the infected sternum and the adjacent costal cartilage were performed in April. The defect was obliterated with the bilateral pectoralis major muscle flaps. After the radical operation, her wound was completely healed, even though the ventilatory support was needed for 24 days because of flail chest due to the anterior chest wall instability. Now she has been free from recurrence for four years. Total sternectomy and pectoralis major muscle plombage seem to be a very effective management in chronic sternal osteomyelitis.

[Flow cytometric analysis of the DNA content in resected thymomas].

Nuclear DNA contents were determined by flow cytometry in 31 resected thymomas. Ten (32%) of the 31 thymomas showed DNA aneuploid, and the presence of aneuploidy was well correlated with advanced clinical stage. Patients with an aneuploid tumor had a poor prognosis than those with a diploid tumor, demonstrating a survival rate of 50% at 7 years in aneuploidy compared to 100% at the same period in diploid patients (p < 0.05). In addition, patients with a high DNA index (DI > or = 1.5) tended to have a poor prognosis than those with a low DI. The analysis of DNA content can be an important prognostic index in patients with a thymoma.

[Application of an expandable metallic Z-type stent for stenosis of the left main bronchus following tuberculosis--a case report].

A 32-year-old man had been suffering from dyspnea on exertion and stridor, which were due to stenosis of the left main bronchus as a complication of bronchial tuberculosis. A three-connection stent, 1.2 cm in diameter and 4.5 cm in length was placed at the site of the bronchial stenosis. Dyspnea disappeared 2 days after the procedure, and the pulmonary function 3 weeks later showed considerable improvements in %FVC, FEV1 and MMF.

[A case of prolonged eosinophilic pneumonia with pulmonary emphysema and bronchial asthma diagnosed by open lung biopsy].

A 65-year-old man was admitted to our hospital complaining of productive cough, dyspnea and stridor. Chest X-ray disclosed overinflation with micronodular infiltrates. Blood examination showed mild eosinophilia and IgE elevation. Pulmonary function test disclosed severe airway obstruction and diffusion capacity impairment. Although clinical improvement was achieved after bronchodilator therapy, laboratory abnormalities continued. Open lung biopsy demonstrated mononuclear cellular and eosinophilic infiltration at alveolar lumen and vessel walls without prominent fibrosis, which was compatible for prolonged eosinophilic pneumonia. From above findings, this case was thought as a prolonged eosinophilic pneumonia combined with pulmonary emphysema and bronchial asthma.

Bilateral internal mammary artery grafts for coronary artery bypass operations in children.

We performed myocardial revascularization with bilateral internal mammary arteries in eight children for coronary artery complications consequent to Kawasaki disease. Subjects included seven boys and one girl, ranging in age from 3 to 13 years (mean age, 8.3 +/- 3.4 years). The body surface area ranged from 0.65 to 1.65 m2 (average, 1.08 +/- 0.35 m2). Three patients had a previous myocardial infarction. The right internal mammary artery was anastomosed to the right coronary artery and the left internal mammary artery was sutured to the left anterior descending artery in all patients. The patients received an average of 2.4 grafts. Magnifying loupes of 3.5 X were used for anastomosis with 8-0 monofilament polypropylene sutures. Subjects were followed up from 12 to 38 months (23 +/- 10.8 months) after operation. All were doing well with no recurrence of angina, and body development was normal, including the sternum and thorax according to chest x-ray films and computed tomography of the chest. Patency of the bilateral internal mammary arteries was 100% in the early (within 1 month) postoperative period and remained so in the late (over 1 year) postoperative period. Anastomotic junctions between the internal mammary artery and the coronary artery developed well angiographically in the late postoperative period. The internal mammary artery is the graft of choice for pediatric myocardial revascularization because of its excellent long-term patency and growth potential. Bilateral internal mammary arteries should be used whenever indicated, and the use of bilateral internal mammary arteries did not adversely influence chest wall development in the children.

[Surgical treatment of chronic empyema and postoperative pulmonary function].

Pulmonary function was evaluated in patients who were operated on for chronic empyema between October 1973 and October 1988. Fourteen patients underwent decortication, 61 were treated by the Kinchu method, 20 were treated by muscle flap and thoracoplasty, and one underwent pleuropnemonectomy. With decortication or the Kinchu method, significant postoperative improvement was noted in both percent forced vital capacity and FEV1/predicted initial capacity. However with muscle flap and thoracoplasty, percent forced vital capacity decreased. Ventilation and perfusion lung scan showed that pulmonary function improved in patients with good re-expansion of the lung who had suffered from short term lung collapse and no pathological changes in collapsed lung parenchyma.

[Surgical treatment for chronic constrictive pericarditis through a combined median sternotomy and left anterolateral thoracotomy].

A 61-year-old and a 64-year-old male patients with chronic calcified constrictive pericarditis underwent pericardiectomy through a combined midsternotomy and anterolateral thoracotomy. X-ray films and CT scans of the chests demonstrated prominent calcification of the pericardium. At cardiac catheterization, the right atrial and ventricular enddiastolic pressures were elevated and the typical dip and plateau pressure curves were found in the right ventricle. A combined midsternotomy and left anterolateral thoracotomy gave a good operative view for the surgery. The post-operative course was uneventful in both patients. This combined approach has greater ease of decorticating the lateral to posterior surfaces of the left ventricle than a simple conventional approach.

[Coronary artery bypass surgery with internal mammary artery grafts: clinical and angiographic results].

We report clinical and angiographic results of coronary artery bypass grafting (CABG) surgery in 307 patients. IMA grafts can be utilized in the wide ranges of patient ages and/or coronary lesions including left main trunk disease, and have good adaptive capability to coronary flow demand with very low probability of atherosclerotic changes. Postoperative (5.2 +/- 4.4 months) patency rates for IMA grafts and SVG were 96% and 86%, respectively; a significant difference (p less than 0.001). From the benefits of this graft, the use of IMA has become a routine procedure in our CABG surgery and the rate of multiple bypasses with IMA grafts has increased recently. The late cardiac events have significantly (p less than 0.05) decreased in patients with the IMA graft than in those without it. We believe that the use of IMA has improved the quality of CABG in Japanese patients and this operative modality can bring better late results than multivessel PTCA.

Postoperative preservation of pulmonary function in patients with chronic empyema thoracis: a one-stage operation.

Twenty-two patients with chronic empyema thoracis underwent decortication. In 11 of them, simple decortication achieved sufficient reexpansion of the lung. In the other 11 patients, our new method was indicated because the pleural space was not closed completely by simple decortication. In our procedure, the parietal wall is collapsed, without rib resection, to contact the surface of the decorticated lung. All 11 patients had a one-stage cure. Two of these 11 patients had bronchopleural fistula. The preoperative and postoperative percentage of vital capacity, percentage of forced expiratory volume in 1 second, arterial oxygen tension, alveolar-arterial oxygen pressure difference, and xenon 133 radiospirometry revealed that pulmonary function was well preserved in patients treated by our method as well as in those undergoing simple decortication. The alveolar-arterial oxygen pressure difference during oxygen inhalation improved significantly (p less than 0.05) after operation compared with the preoperative values in both groups. From the pulmonary function studies, we conclude that our method achieves results comparable with those of simple decortication for the treatment of chronic empyema thoracis. Our procedure is indicated in patients for whom it is thought simple decortication will not lead to primary cure of empyema.