[Changing pattern of the respiratory function associated with resected lung lobe].

Respiratory function before and 2 months after lung lobectomy was analyzed associated with resected lobe. Post- or preoperative ratios of FEV1.0 or VC were compared among (1) predicted value by the number of subsegments using bronchofiberscopy, (2) predicted value by the lobar volume ratio using computed tomography (CT), and (3) actually measured value. Using subsegments method, post- or preoperative predicted VC ratios were 85 +/- 1% after right upper lobectomy (RU), 69 +/- 1% after right lower lobetomy (RL), 74 +/- 1% after left upper lobectomy (LU), and 75 +/- 1% after left lower lobectomy (LL). Using CT method, post- or preoperative predicted VC ratios were 80 +/- 2% after RU, 76 +/- 4% after RL, 74 +/- 2% after LU, and 79 +/- 3% after LL. Actually measured post- or preoperative FEV1.0 ratios were 82 +/- 3% after RU, 89 +/- 8% after RL, 73 +/- 3% after LU, and 86 +/- 5% after LL, and the VC ratios were 88 +/- 5% after RU, 79 +/- 3% after RL, 77 +/- 4% after LU, and 94 +/- 3% after LL. In the FEV1.0 analysis using both subsegments method and CT method, the predicted value was correlated with upper lobectomy but was overestimated in case of lower lobectomy. This phenomenon might be caused by the postoperative bronchial branching deformity after upper lobectomy. In the VC analysis using subsegments method, the predicted value was correlated with upper lobectomy but was overestimated in case of lower lobectomy. Meanwhile, in the VC analysis using CT method, the predicted value was correlated with RL or LU but was overestimated in case of RU or LL. This may due to the fact that RL and LU had large lobar volumes. In conclusion, postoperative predicted and actually measured values were different associated with resected lobe. In the FEV1.0 and VC analysis using subsegments method, the predicted value was strongly correlated with upper lobectomy but was overestimated (10%) in case of lower lobectomy.

[Multiple synchronous intrathoracic neurilemmomas who had a past history of neurilemmoma on the abdominal wall; report of a case].

A 66-year-old female, who had received a surgery of the neurilemmoma on the abdominal wall 6 years ago, was referred to our hospital because of a chest X-ray abnormality. Chest computed tomography (CT) revealed 3 tumors in the left chest wall. One tumor arised from the 7th intercostal nerve and 2 tumors from 8th nerve. These tumors were surgically removed by video-assisted thoracic surgery. These tumors are histopathologically diagnosed as neurilemmoma and have the same characteristics with previously resected abdominal wall tumor.

[Postoperative temporal elevation of tumor marker in primary lung cancer patients].

Serum tumor marker measurement in addition to radiological examination is useful to detect postoperative recurrence and metastasis. Surgically treated 8 primary non-small cell lung cancer patients who showed negative serum tumor marker postoperatively elevated their markers temporally. Five of the 8 patients did not show recurrence or metastasis in their last confirmation days. These 5 patients had inflammatory disease when the postoperative marker became positive temporally. Remaining 3 patients did not have inflammatory disease when the marker elevated temporally. The marker of the 3 patients became negative again, however, the 3 patients showed recurrence or metastasis during 1 year after temporally elevated day. In conclusion, if there is no inflammatory disease when the negative marker becomes positive temporally, the recurrence or metastasis may be observed during 1 year after temporally elevated day. And when the recurrence or metastasis is observed radiologically, the marker may become negative.

[Experience with invasive thymoma presenting pleural dissemination].

A 61-year-old man was admitted to Showa University Hospital because of a myasthenia gravis. Chest computed tomography revealed a mediastinal invasive tumor. During surgery, invasion to the pericardium and dissemination on the left visceral pleura and the left diaphragm were observed. Extended thymo-thymectomy and partial resection of the pericardium, left lung, and diaphragm were performed. Incomplete resection was achieved because of the dissemination on the diaphragm. Chemotherapy using ADOC and radiotherapy for mediastinum and left diaphragm were done. Four years after surgery, neither recurrence of the tumor nor myasthenia gravis was observed.

[Acute pulmonary thromboembolism complicating lung lobectomy; report of a case].

Acute pulmonary thromboembolism is fatal if the diagnosis and treatments are delayed. Here we present a case of acute thromboembolism to the right and left pulmonary arteries after right lung lobar resection. A 52-year-old woman who admitted to our hospital with lung cancer was performed right upper lobectomy with mediastinal lymph node dissection (pT1N0M0, well differentiated adenocarcinoma). Two days after surgery, she complained sudden chest discomfort and dyspnea. The blood pressure and oxygen saturation were rapidly decreased. Because there was no lung edema or atelectasis in the chest portable roentgenogram and no ischemic change in the electrocardiogram, pulmonary thromboembolism was suspected and emergency chest computed tomography (CT) was performed. The CT showed left and right pulmonary arterial thromboembolism and immediate anti-coagulator therapy was started. Her condition was improved and chest CT, which was performed three days after the onset of the thromboembolism, showed decreased but still remained thrombus. The anti-coagulator therapy was continued and one month after the onset of the thromboembolism, thrombus was disappeared on chest CT. She is doing well 17 months after surgery. Early diagnosis and treatments are critical for the pulmonary thromboembolism.

[Surgically treated pancoast tumor].

A 40-year-old male was detected his right apical lung tumor by roentgenographic screening on January 1997, but he did not refer to a hospital since he had no symptom. He went a orthopedics because of his right chest, back, and arm pain on October 1997, and he received traction and physical therapy. He went roentgenographic screening again on January 1998 and he was pointed out that the tumor increased. He admitted our hospital. Biopsy using bronchofiberscopy revealed adenocarcinoma and induction radiotherapy (40 Gy) was performed. Right upper lobectomy with chest wall resection and lymph node dissection was performed under hook approach. This approach was useful to dissect the tumor from the invaded plexus brachialis. Postoperative radio-chemotherapy was added but the patient died 7-postoperative months because of multiple metastases. Early detection should be led to early starting of the therapy.

[Endobronchial brachytherapy for intra-luminal recurrence after lung cancer resection].

A 63-year-old man who had squamous cell carcinoma in left lung was received left lower lobectomy with lymph node dissection (pT3N0M0). Twenty months after surgery, the patient showed bloody sputum and bronchofiberscopy revealed intra-luminal recurrence on trachea. Endobronchial brachytherapy in combination with external beam radiotherapy was selected and complete remission was achieved. After the brachytherapy, bronchitis was observed and was healed 23 months after the therapy.

Coronary artery bypass grafting for coronary aneurysms due to Kawasaki disease.

We report a 23-year-old man who underwent coronary artery bypass grafting (CABG) for coronary aneurysms associated with Kawasaki disease using the left internal thoracic artery (LITA) and right gastroepiploic artery (RGEA) after a second myocardial infarction (MI). Preoperatively, this patient showed repetitive occlusion and recanalization of coronary artery flow without coronary stenosis. Indication of bypass surgery in Kawasaki disease is usually associated with stenosis. However, even an aneurysm alone should be an indication of surgery if there is any kind of ischemic event.

Changing predictors of postoperative mortality in acute type A aortic dissection. Is only coronary artery compromise significant?

OBJECTIVES: Rapid emergency transport and early diagnosis and surgical treatment for acute type A aortic dissection have improved postoperative survival, which has, however, plateaued at about 80%. End-organ malperfusion is regarded as a strong predictor of postoperative mortality, replacing factors such as cardiac tamponade complications, aortic rupture, and left ventricular dysfunction due to aortic insufficiency. It is thus important to reevaluate risk factors for surgical death to assess current therapeutic strategies. METHODS: We statistically analyzed potential risk factors for perioperative death in 88 patients undergoing surgical repair for type A aortic dissection between January 1990 and December 1999. RESULTS: Univariate analysis showed that cardiopulmonary arrest (adjusted odds ratio: 13.78; p < 0.01) and malperfusion of more than 1 vital organ (adjusted odds ratio 4.97, p < 0.01), especially myocardial ischemia due to coronary artery dissection (adjusted odds ratio 3.21, p < 0.05), significantly increased the likelihood of operative death. Multivariate logistic regression analysis showed only cardiopulmonary arrest (p < 0.01) and concomitant coronary artery bypass grafting necessitated in cases complicated by evolving myocardial infarction (p < 0.05) to be independent predictors of postoperative mortality. CONCLUSION: Preoperative complication from coronary dissection was the most important predictor of early postoperative mortality in this series. In such cases, rapid surgical intervention before myocardial infarction develops is vital to saving lives.

[A surgically treated case of capsulated thymoma with thymic cyst].

A 56-year-old woman was pointed out an abnormal shadow on chest roentgenogram. Chest CT and MRI showed a solid mass with a cyst at right anterior mediastinum. Clinical diagnosis was thymoma with cyst, and surgical excision was performed. The histopathological examination of the resected specimen demonstrated that the epithelia of the cyst wall was single cuboidal or squamous cells and contained some foci of thymic tissue. The solid mass was capsulated and predominantly composed of lymphocytes. The pathological diagnosis was a thymoma (predominantly lymphocytic type) with thymic cyst. She is doing well for 10 years postoperatively.

[Incomplete resection for primary non-small cell lung cancer].

A superior outcome is observed for cases of complete resection compared with that of incomplete resection. The reason and the countermeasure of the incomplete resection for lung cancer were analyzed. During 12 years, 274 patients with primary non-small cell lung cancer were surgically treated. Two hundred and forty-eight patients underwent complete resection and 26 incomplete resection. Three-year survival was 62% for patients with complete resection and 17% for patients with incomplete resection. Survival rates were not different between the paroative reduction surgery and the exploratory thoracotomy. Tiny but multiple pleural dissemination or small amount of the malignant pleurfal effusion was not able to detect preoperatively. In these cases, preoperative thoracoscopic observation may useful for avoiding the meaningless thoracotomy. Postoperative radiochemotherapy may improve the prognosis if the therapy is effective. Chemotherapy on the basis of the sensitivity assay is warranted.

Extended surgery with en bloc resection of the right common iliac vessels for lymph node metastasis of mucinous colon carcinoma: report of a case.

We report herein the case of a 63-year-old woman who underwent surgery for recurrent mucinous carcinoma of the cecum. Recurrent metastatic lymph nodes had invaded the right common iliac vessels and right ureter, but she had no distant metastases and no peritoneal dissemination. Extended surgery with en bloc resection of the right iliac vessels and right ureter, and femorofemoral bypass were performed. Postoperatively, several complications developed which were successfully treated by further operations. By 1 year after surgery, she had no recurrent tumors on radiological examination, suggesting that our aggressive surgery with resection of the invaded regional vessels had effectively removed the recurrent tumors. This procedure may therefore significantly prolong the survival time and improve the quality of life of such patients.

Extra-anatomical bypass grafting for coarctation of the aorta associated with annuloaortic ectasia. Long-term outcome.

Two patients each with a rare combination of aortic coarctation and annuloaortic ectasia underwent successful single-stage repair in which the aortic root was reconstructed with a valved conduit, and an extra-anatomical bypass was made by grafting from the ascending to the abdominal aorta. Although the long-term outcome of such a long extra-anatomical bypass graft has not yet been established, the use of the graft for reducing the risk to coarctation-related complications during the early and late postoperative periods appears promising.

[Leiomyoma of the esophagus shown as a cervical tumor].

A 44-year-old female was admitted to our hospital because of the left cervical tumor. Radiologic examination showed that the tumor was 5 cm in diameter and was inhomogeneous. The tumor was spread to the upper mediastinum. Esophagoscopy showed that the tumor was covered by the normal mucosa. Percutaneous fine needle biopsy did not appear the histopathological diagnosis. The patient underwent surgical resection through the cervical approach and the tumor was located between the mucosal and muscular layers of the esophagus. The tumor was enucleated without any complication. Histopathological diagnosis was leiomyoma. Postoperative course was uneventful. Expecting diagnosis and positive complete resection is recommended for leiomyoma of the esophagus.

Benign solitary fibrous tumor of the parietal pleura which invaded the intercostal muscle.

A 29-year-old woman who underwent evaluation for a 3-month history of left-sided back pain proved to have a left pleural tumor accompanied by a bloody pleural effusion (cytological class II). Three years previously, a chest roentgenogram had been normal. The tumor originated from the parietal pleura at the level of the first three intercostal muscles and was excised completely in continuity with these muscles, including a margin of normal muscle. The tumor measured 15x12 cm and the pathologic diagnosis was benign solitary fibrous tumor; while the tumor invaded the intercostal muscles, no histologically malignant features were present. Long-term follow-up is planned because a possibility of local recurrence exists.

Post radiation inflammatory malignant fibrous histiocytoma arising from the chest wall.

A 59-year-old man who underwent radiation therapy (41 Gy) to the mediastinum through the anterior chest for Hodgkin's disease presented with a painful anterior chest wall tumor 18 years later. The tumor originated from the left parasternal region and was excised with the sternum. Chest wall reconstruction was performed. The tumor measured 45 x 45 mm and invaded the sternum. The pathologic diagnosis was malignant fibrous histiocytoma. Early and complete excision of the tumor is indicated.

[Efficacy of off-pump coronary artery bypass grafting in patients requiring noncardiac operations].

Off-pump coronary artery bypass grafting was performed for patients with concomitant disease requiring noncardiac operations. Eight patients underwent CABG prior to or at the same time of noncardiac operation: lung cancer (2), gastric cancer (2), arteriosclerotic occlusive disease (2), abdominal aortic aneurysm (1), aorto-iliac occlusive disease (1). Of these, there were 6 patients who underwent off-pump CABG. Two patients underwent conventional CABG with extracorporeal circulation. Off-pump CABG was performed through a median sternotomy and small left thoracotomy. One patient received quadruple grafts, and another one received double, and 4 received single grafting. Simultaneous noncardiac operations were carried out in 3 patients (Y-grafting, femoro-femoral bypass, mediastinal lymphnode biopsy). The other 3 patients underwent subsequent operations (axillo-femoro-popliteal bypass, aorto-femoral bypass, subtotal gastrectomy). However, of the 2 patients with conventional CABG, 1 died of multiple metastasis after lobectomy of lung cancer that might have been affected by the extra-corporeal circulation. Off-pump CABG is efficient in patients with concomitant disease requiring noncardiac operations.

Analysis of the anatomic changes in the thoracic cage after a lung resection using magnetic resonance imaging.

The thoracic cage after a lung resection is filled by the remaining lobes, the elevated diaphragm, the diminished thoracic cage, and by mediastinal shifting. The changes in the thorax after a lung resection were quantified using magnetic resonance imaging. The study group consisted of 39 patients who had undergone a lobectomy, four who had undergone a pneumonectomy, and 14 controls. The left ventricular angle, ascending aortic angle, mediastinal shift, longitudinal length of the thoracic cage, the distance between the thoracic apex and the level of the aortic valve, and diaphragmatic elevation were all measured. After a right lower lobectomy, the mediastinum shifted more rightward than after a right upper lobectomy. The diaphragm became more greatly elevated after a right upper lobectomy than after a right lower lobectomy. When a chest wall resection was added to a right upper lobectomy, the mediastinal anatomical changes decreased. After a left upper lobectomy, the degree of mediastinal shifting was greater than after a left lower lobectomy. A left upper lobectomy shifted the mediastinum at the level of the right atrium. This method is easily reproducible and was found to be effective for quantifying the changes in the thorax after a lung resection.

[Surgically treated infectious giant bulla].

A 32-year-old man who underwent evaluation for dyspnea and left chest pain proved to have a left pneumothorax and a right giant bulla. After surgery for the left pneumothorax, drug induced liver injury was observed. Seventeen days after surgery, left giant bulla was infected and niveau formation was seen with high fever. After administration of antibiotics, the niveau was disappeared and the body temperature was down, however, drug induced liver injury was caused. After that, again, the niveau formation was noticed in the right bulla. We speculated that adequate drug therapy could not used because of liver injury if the right bulla would be infected one more time. Bullectomy of the right lung was performed. One year after surgery, there were no signs of infection. We usually administer the adequate antibiotics against the infectious giant bulla without surgical therapy because the bulla will be reduced with the infection. However, there is a situation like this case that surgical treatment is required because of the drug induced liver injury.