[Order-made therapy for early lung cancer patients].

To give optimal treatment to the patients with early lung cancer, we are trying to establish two new techniques to select the patients of poor prognosis and sensitive to the chemotherapy. To pick up the patients of poor prognosis nevertheless the early stage of their lung cancer, we are developing a new method to detect cancer cells floating in the peripheral blood flow with RT-PCR using cancer specific mRNA. To choose optimal chemotherapy regimens, we have established a new chemosensitivity testing (collagen gel droplet embedded culture drug sensitivity test: CDDST) for non-small cell lung cancer (NSCLC). Median survival time (MST) of the patients (n = 11) with unresectable NSCLC, who were given optimal chemotherapy according to CDDST, was 15.8 months and MST of those (n = 16) who did not have any sensitive agents according to CDDST was 5.6 months. There was significant difference between these two groups (p = 0.0048; logrank).

One hundred consecutive treatments with holmium: YAG laser for pulmonary bullae: especially in conjunction with gelatin-resorcinol formaldehyde-glutaraldehyde glue adhesion.

BACKGROUND AND OBJECTIVE: We have widely used a Ho:YAG laser to treat bullae thoracoscopically. STUDY DESIGN/MATERIALS AND METHODS: Bullae with broad necks were treated with a Ho:YAG laser thoracoscopically. Because one patient relapsed after application of fibrin glue in the early period, a DEXON (polyglycolic acid) mesh patch soaked in fibrin glue was used through a 2-cm opening in the subsequent cases. Lastly, gelatin-resorcinol formaldehyde-glutaraldehyde (GRFG) glue was applied through a 5-mm opening instead of a DEXON mesh after coagulation. RESULTS: In the 38 patients patched with DEXON mesh soaked in fibrin glue and 56 patched with GRFG glue after coagulation, none relapsed. CONCLUSION: Combined uses of fibrin glue plus DEXON mesh or GRFG glue were effective when bullae were treated with the Ho:YAG laser. However, the wound was smaller and more cosmetic in the GRFG glue group than in the DEXON mesh plus fibrin glue group.

Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy.

BACKGROUND: Data regarding pulmonary function and prognosis after video-assisted thoracic surgery lobectomy are limited. METHODS: From September 1992 to April 2000, 204 video-assisted thoracic surgery lobectomies were performed, and their preoperative and postoperative pulmonary function test results and prognoses were evaluated. RESULTS: The postoperative to preoperative ratio of pulmonary function tests (vital capacity and forced expiratory volume in 1 s) were better in video-assisted thoracic surgery lobectomy than in open thoracotomy (p < 0.0001). Furthermore, the 5-year survival rate of pathologic stage I lung cancers after video-assisted thoracic surgery was 97.0%, whereas that after open thoracotomy was 78.5% (p = 0.0173; Mantel-Cox). CONCLUSIONS: Pulmonary function and prognosis were far better after video-assisted thoracic surgery lobectomy than after open thoracotomy.

Obstructive jaundice caused by a huge liver cyst riding on the hilum: report of a case.

A 71-year-old man presented to our hospital with obstructive jaundice, found to be caused by a huge liver cyst which was centrally located and riding on the hilum. Percutaneous transhepatic cyst drainage was performed, following which obstruction of the bile duct was relieved and the jaundice subsided. As jaundice recurred after removal of the drainage tube, the patient underwent deroofing, since when he has remained well. Only 13 cases of liver cysts producing obstructive jaundice have been reported in the English literature, most of which were characteristically enormous, located centrally, and riding on the hilum. Liver cysts possessing such features are likely to cause obstructive jaundice by compressing the hepatic hilum. Cyst drainage is helpful for ameliorating the jaundice and making an accurate diagnosis; however, subsequent deroofing or injection therapy is necessary to prevent recurrence.

Video-assisted thoracic surgery (VATS) lobectomy: the Japanese experience.

Between September 1992 and October 1997, we performed 128 video-assisted thoracic surgery (VATS) lobectomies. The indications for surgery were 103 cases of lung cancer, 11 cases of bronchiectasis, 8 cases of granuloma, 4 cases of benign lesions, and 2 cases of metastatic tumors. Of the 103 cases of lung cancer, 62 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, and the 4-year survival rate of final stage I lung cancer was 94.4%. VATS lobectomy is far less invasive than open thoracotomy, and survival rates after VATS lobectomy with extended lymph node dissection are comparable with those after open thoracotomy. Thus, VATS lobectomy with extended lymph node dissection should be considered as a standard surgical alternative to open thoracotomy for stage I lung cancer.

Treating bullous lung disease with Holmium YAG laser in conjunction with fibrin glue and DEXON mesh.

BACKGROUND AND OBJECTIVE: Holmium YAG (Ho:YAG) laser energy is highly absorbed by water, and this property is useful to uniformly ablate pulmonary bullae. The current study summarizes the data of a 39-month follow-up of patients treated for bullae with a Ho:YAG laser. STUDY DESIGN/MATERIALS AND METHODS: We used a Ho:YAG laser from August 1994 to April 1997 to treat small pulmonary bullae in 50 patients. For the first five patients, Ho:YAG laser ablation was followed by resection for histological assessment. In the next six patients, fibrin glue was applied following bullae ablation with the Ho:YAG laser. In all subsequent patients, a DEXON, (polyglycolic acid) mesh patch soaked in fibrin glue was employed after ablation. RESULTS: From the six patients receiving only the fibrin glue following laser ablation, delayed pneumothorax developed in one patient. In the subsequent 39 patients patched with DEXON mesh soaked in fibrin glue, none encountered delayed pneumothorax. CONCLUSION: The combined use of fibrin glue and Dexon mesh with the Ho:YAG laser may be an effective technique for treating bullous lung disease.

Lobectomy with extended lymph node dissection by video-assisted thoracic surgery for lung cancer.

BACKGROUND: Between September 1992 and September 1996, we performed 88 VATS (video-assisted thoracic surgery) lobectomies and two VATS pneumonectomies. METHODS: The indications for surgery were 68 cases of lung cancer, nine cases of bronchiectasis, six cases of tuberculosis, and seven cases of benign lesions. Of the 68 cases of lung cancer, 36 were treated by VATS lobectomy with extended lymph node dissection for clinical stage I lung cancer, making full use of recently developed devices for thoracoscopic surgery, such as roticulating endoscissors, miniretractors, endoclips, and harmonic scalpels. RESULTS: Twenty-four lymph nodes were resected on average (range, 10 to 51) by VATS. This number was comparable to lymph nodes resected in open thoracotomy during the same period. Among the 36 patients who underwent extended lymph node dissection, 20 showed no lymph node metastasis postoperatively (stage I), while 16 had N1 or N2 cancer. All patients with stage I cancer have survived 4 to 36 months (median: 17 months) with no signs of recurrence. CONCLUSIONS: This survival of stage I lung cancer after VATS is comparable to that of open thoracotomy. We thus believe that VATS lobectomy with extended lymph node dissection can be an alternative to standard posterolateral thoracotomy for stage I lung cancer.

Experimental tracheal replacement using the esophagus and an expandable metallic stent.

An experimental study was conducted to investigate whether a segment of autogenous esophagus with its lumen supported by an expandable metallic stent (EMS) could be successfully used as a tracheal substitute. Seven rings of the cervical trachea were circumferentially removed and reconstructed by interposing a pedicled segment of the esophagus with an EMS in six mongrel dogs. The interposed esophagus was observed endoscopically at various stages after the operation. By 1 month, the EMS was found to be buried under the esophageal mucosa, and the lumen was patent. The dogs died 5, 17, 61, 92, 210, and 478 days after the operation, but the cause of death could not be determined by postmortem examination and no respiratory tract complications were detected. The results of this study indicated that a segment of the esophagus with its lumen supported by an EMS could work as a reliable tracheal substitute, though its practical use is not clinically feasible. Nevertheless, we conclude that some autogenous material other than the esophagus with its lumen supported by an EMS could provide a feasible method for tracheal replacement.

[A case of traumatic diaphragmatic hernia repaired 40 years after the injury].

A 65-year-old male complaining dyspnea on exertion and epigastric discomfort was diagnosed to have left traumatic diaphragmatic hernia elsewhere and referred to Keio university Hospital for treatment. He had thoracicio-abdominal trauma which was conservatively treated, 40 years ago. Because he was symptomatic and the possibility of future strangulation could not be denied, surgical repair of the hernia was performed. The defect in the diaphragm was too large to be directly sutured and it was repaired with GORE-TEX patch. The gastric fundus partially prolapsed in the paraesophageal region, but the diaphragm was repaired quite satisfactorily otherwise. Pulmonary function and dyspnea on exertion improved.

Bronchoplastic procedures for tuberculous bronchial stenosis.

Thirty-six patients underwent tracheobronchoplastic procedures for treatment of tuberculous tracheobronchial stenosis. The modes of operations were left upper sleeve lobectomy in 13 patients, sleeve resection of the left main bronchus in 12 patients (two underwent concomitant left upper lobectomy), right upper sleeve lobectomy in five patients, sleeve resection of the right intermediate bronchus in two patients, right sleeve superior segmentectomy of the lower lobe in one patient, sleeve resection of the trachea with concomitant left pneumonectomy in one patient, carinal resection with right upper sleeve lobectomy and middle lobectomy in one patient, and dilatation of the left main bronchus with a free skin graft reinforced with a steel wire in one patient. One patient died of pulmonary edema of unknown cause on the first postoperative day. Anastomotic stenosis occurred in seven patients. One of these patients underwent reoperation and six underwent endoscopic dilatation. One patient died in the hospital of massive bleeding during endoscopic dilatation 4 months after operation. Slight to moderate stenosis resulted in the remaining patients. Although there are some complications, we believe bronchoplastic operation is worthwhile for restoring pulmonary function in patients with tuberculous tracheobronchial stenosis.

[Multidisciplinary treatment for a patient with recurrent thymoma associated with myasthenia gravis (MG), pure red cell aplasia (PRCA), and hypogammaglobulinemia].

The patient is 62-year-old female. When she was 43 years old, MG occurred. At age of 49 years thymoma was found and complete thymectomy (stage III) and postsurgical irradiation were performed. At age of 57 years pleural dissemination of the thymoma was found. Chemotherapy was effective but did not obtain total tumor cell kill. Though chemotherapy has been repeated for each tumor regrowth, the regimen used at first recurrence became ineffective and the interval between tumor regrowth became shorter. This year, when she is 62 years old, PRCA and hypogammaglobulinemia were accompanied with the forth tumor regrowth.

[Nd-YAG laser therapy of tracheobronchial lesions by malignant tumor].

Thirty-seven patients with tracheobronchial lesions by malignant tumor were treated with Nd-YAG laser. Thirty-seven patients were twenty-three males and fourteen females and ages ranged from 34 to 79 years. Diseases included were primary tracheal tumor in 3 cases, lung cancer in 16 (8 squamous cell carcinoma, 5 adenocarcinoma, 2 large cell carcinoma, 1 small cell carcinoma), cancer of adjacent organs in 9 (5 thyroid cancers, 4 esophageal cancers), and metastatic cancer to the lung or mediastinal lymph nodes in 9 (4 renal cell carcinoma, 2 thyroid cancer, one patient respectively, colon cancer and breast cancer). Intermittent irradiation of YAG laser was done for 0.5 second at 30-40 Watt through flexible bronchoscope under local anesthesia. It was repeated 1 to 41 times (mean 4.1 times) and energy amount was 148 Joules to 18,513 Joules (mean 3,305 J). The result was; stenosis disappeared in 22 cases (59.4%), improved in 14 (37.8%), and in one case YAG laser therapy discontinued due to intractable bleeding. The Nd-YAG laser therapy for tracheobronchial lesions by malignant tumor is very useful to improve dyspnea or atelectasis.