[Intraoperative right-to-left shunting induced by supine position in simultaneous lung resection with repair of atrial septal defect].

This report describes the case of a 49-year-old woman, who was suffered severe hypoxemia attributable to right-to-left shunting through an atrial septal defect (ASD) during the combined surgery for lung cancer and ASD in supine position. Right-to-left shunting has been reported to occur after lung resection but not during it. According to our continuous measurement of pulmonary arterial pressure and oxygen saturation, changes in hemodynamics during lobectomy in supine position was supposed to differ from that in lateral position, which may contribute to right-to-left shunting. A combined lung resection with heart surgery was performed safely and resulted in preventing postoperative complications induced by ASD.

[Uncomplicated covering technique for preventing the recurrence in the thoracoscopic surgery for pneumothorax].

Reinforcement of the visceral pleura along the stapled line and prevention of lung-chest wall adhesion is supposed to decrease the recurrence rate of video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax. Covering over the stapled line with an absorbable mesh; polyglycolic acid and regenerative oxidized cellulose mesh, and a fibrin glue is recognized useful for that, although, it tends to be troublesome in VATS procedure. In this article, we present the knack of the covering method: (1) installation of the absorbable mesh on the visceral pleura; a folded absorbable mesh is hold with the endoscopic autosuture or grasping foreceps and placed on the pleura without curling up; (2) installation of a fibrin glue over the pleura and the mesh using a rubbing device (U-rod); each of the fibrinogen solution and the thrombin solution are applied and rubbed on the pleura and the mesh. Surgeons can perform them without any complicated technique.

[Preoperative assessment of myocardial ischemia in thoracic surgery for lung cancer].

BACKGROUND: Morbidity of myocardial ischemia in the thoracic surgery for lung cancer has been reported in the literatures, although, the risk of myocardial ischemia is not well identified preoperatively. OBJECTIVES: The aim of this study was to describe the prevalence of severe coronary stenosis in the thoracic surgery for lung cancer. METHODS: From January 2004 to December 2006, data were collected concerning 175 consecutive patients underwent lung resection for lung cancer. Prior to the surgery, we performed coronary angiography on the patients with either ischemic change in the exercise electrocardiogram (ECG) testing or comorbid conditions (current or previous smoking, hypertention, diabetes mellitus, hyperlipidemia or history of chest pain). RESULTS: Fifty-eight (33%) patients underwent coronary angiography. Coronary stenosis was detected in 19 patients (10.9%), including 6 patients (3.4%) with severe stenosis. These 6 patients received percutaneous coronary intervention or coronary artery bypass grafting prior to the lung resection, which resulted in no incidence of perioperative myocardial ischemia. Three of 6 patients with severe stenosis were negative for ischemic changes in exercise ECG testing. CONCLUSION: The prevalence of severe coronary stenosis is 3.4%, which is supposed to indicate the risk of perioperative myocardial ischemia in the thoracic surgery for lung cancer.

[Localized nodular pulmonary amyloidosis; report of a case].

A 66-year-old female was admitted to our hospital because of chest abnormal shadow. Chest X-ray and chest computed tomography (CT) on admission showed a nodule in the right middle lobe. The nodule was not diagnosed preoperatively by a bronchoscopy. She underwent partial lung resection including the nodule with video-assisted thoracoscopic surgery. The pathological diagnosis was amyloidosis, and we diagnosed her illness as localized nodular pulmonary amyloidosis, since the amyloid substance was type AL. In addition, electron microscopy showed amyloid as straightly fibrous materials in alveolus. It is difficult to differentiate amyloidosis from lung cancer by radiology, and the lung biopsy with video-assisted thoracoscopic surgery is useful and a safety way to establish diagnosis.

[The establishment of the styles of video-assisted thoracoscopic surgery for spontaneous pneumothorax].

Video-assisted thoracoscopic surgery (VATS) has been widely used in the treatment of a pneumothorax, but the high incidence of recurrence from spontaneous pneumothorax after VATS is an important problem. In this study, we classified the groups into two categories from the thoracoscopic observations, and discussed whether or not there was reappearance of pneumothorax. In addition, we examined whether adjunctive procedure contributes to recurrent of pneumothorax after operation or not. We concluded that there is a tendency to recurrence in the group with multiple and skip lesions in the lung, and then concluded that the cases apical covering with absorbable material sheet and the use of fibrin glue spray was thought to be effective of recurrence of pneumothorax in cases of multiple and skip lesions from the intraoperative findings through the thoracoscopes. Finally, we examined application of Foley catheter for spontaneous pneumothorax under VATS. It is possible that the application of Foley catheter to prevention against recurrence of pneumothorax is a valid method.

[Catamenial pneumothorax long-term monitored by serum levels of CA 125; report of a case].

A 46-year-old woman was admitted to our hospital because of the repeating right chest pain. Chest X-ray showed a right pneumothorax. This symptom corresponded with her mensturations and elevated serum levels of CA 125. We diagnosed catamenial pneumothorax. Hormones therapy was not performed because severe side effects. For that reason we performed thoracoscopic surgery. We found many little sized fistulas on diaphragm and blue berry spots on right upper lobe during the operation. She didn't recurrence for 2 years after that operation.

[A case of simultaneous off-pump CABG and left lower lobectomy via left anterolateral thoracotomy].

Surgical management for simultaneous pulmonary resection and cardiac surgery remains controversial. We report a case of coexisting lung carcinoma and angina pectoris who was managed successfully with a concomitant operation via the left anterolateral thoracotomy through the fourth intercostal space. After left lower lobectomy, left anterior descending and distal circumflex arteries were anastomosed with composite left internal thoracic and radial artery grafts without use of cardiopulmonary bypass. Both less invasive CABG and curative resection of lung carcinoma were achieved with these procedures.

[Excision of a chronic expanding hematoma developing after thoracoplasty: a case report].

The patient was a 56-year-old woman who had undergone thoracoplasty for right pulmonary tuberculosis 31 years previously. She consulted her local physician complaining of right shoulder pain. Chest X-rays revealed a mass of the thoracic wall, and the patient was referred to our department. Because of the difficulty in making a diagnosis by needle biopsy and of increased pain, operation was done. The mass was covered by a fibrous capsule, and its center was composed of structure-less material including fibrin and blood cells. A diagnosis of chronic expanding hematoma developing after thoracoplasty was made. Beneath the hematoma, a 5 mm diameter hole communicated with the thoracic cavity. Chronic inflammation at this site appeared to have caused the hematoma.

[Retroperitoneal fibrosis with involvement up to the mediastinal space].

A 60-year-old man presented with sudden palpitations in September 1993, and was admitted to hospital with a diagnosis of atrial fibrillation and heart failure. The patient was suspected of having collagen disease, because of a positive test for antinuclear antibodies and a high sedimentation rate. He was referred to lou hospital. Chest radiographic findings were suggestive of cardiomegaly and cardiac murmurs were audible, which indicated the presence of heart disease. A chest Ct scan revealed a lesion surrounding the intramediastinal large vessels and the heart from the level of the confluence of the left brachiocephalic vein and the superior vena cava. Suspicion of a mediastinal tumor led the patient to be admitted to the respiratory department. Percutaneous needle biopsy with a Trucut needle revealed non-specific chronic inflammation. An abdominal CT scan showed that the lesion surrounding the descending aorta traversed the diaphragm, reached the renal pelvis along both renal arteries, and caused narrowing of the ureter and left hydronephrosis. Based on these findings, retroperitoneal fibrosis was diagnosed. Treatment with steroids caused the lesion to shrink.

[A case of multiple inthorathoracic neurilemmoma with cutaneous lesions].

A 33-year-old man with right inguinal mass was admitted to our hospital because of an abnormal shadow on his chest X-ray film. Surgery was performed. These tumors originating from the right 7th, 8th intercostal and right cutaneous femoralis nerve were removed. Histologically, excised tumors were diagnosed as neurilemmoma. There had been only 4 cases of inthorathoracic multiple neurilemmoma with skin lesion, in Japan. We reviewed and discussed the Japanese literature.

[Nonfunctioning paraganglioma of the posterior mediastinum].

A 23-year-old man, complaining of a discomfort in the chest, saw a physician nearby and was pointed out chest abnormal shadow in chest X-ray. He was admitted to our hospital for surgery. As a result of a close check-up at this department, a giant tumor extending from above the right diaphragm to the posterior mediastinum was found. Physical findings in the preoperative examination and general examinations showed no abnormality. The operation was performed and was diagnosed as paraganglioma. This tumor is abundant in blood vessels. Thus, preoperative angiography and securing of the field of operation in treating the blood vessels were considered indispensable for the safety of operation.

[A case of enchondroma protuberance with destroying the rib bone].

A 42-year-old female was referred to our hospital because of a tumor shadow in the right lung fields. Tomography revealed a tumor which had destroyed the right 4th rib. Under the diagnosis of malignant tumor, she was treated by radical en bloc excision. The pathological diagnosis was enchondroma.

[Radioaerosol inhalation and perfusion imaging studies in immediate postoperative phase after lobectomy].

In order to determine the changes in pulmonary ventilation-perfusion imaging after lobectomies, we examined 11 patients using radioaerosol inhalation and perfusion scintigraphies, before and after the operations. We employed 99mTc-labeled albumin aerosol generated by a jet nebulizer for the inhalation imaging, and 99mTc-labeled macroaggregated albumin for the perfusion imaging, respectively. Prior to the operations, there were no (major) defects of imagings on the lung fields. Immediately after the operations, however, we could not detect any abnormal findings on chest roentgenograms, we found detects of imagings on the lung fields in either inhalation or perfusion scintigraphy whose area were mismatching. It took more than 3 weeks for these defects of imagings to disappear. In conclusion, these findings suggest that postoperative hypoxemia might be occurred by these mismatchings.

[Lung function after lobectomy in chronic pulmonary emphysema].

We compared the prediction of postoperative pulmonary function in two groups: chronic pulmonary emphysema (CPE) group (n = 30) and normal control group (n = 41). These patients had a lobectomy because of lung cancer. We measured pulmonary function test (FVC, EFV1, TLC, FRC, RV, DLco), and pulmonary perfusion scan before and after surgery. We found correlation between the predicted and measured postoperative values very close in control group. Whereas, in CPE group, these correlations were very low especially in FVC and FEV1. We also calculated the pulmonary function on the operated and the non-operated sides. The correlation were very high without FEV1 in control group and all the measured values did not correlate to the predicted values. On the non-operated side, the correlations were high in both control and CPE groups. From these results we can conclude that it is difficult to predict the postoperative pulmonary function in the case of chronic pulmonary emphysema.

[OKT4 epitope deficiency in a patient with thymoma and hypogammaglobulinemia].

A 61-year-old male stonecutter was in excellent health until December 1988 when he was admitted to Miyagikenritsu Semine Hospital with an abnormality on chest X-ray film. Chest X-ray film revealed a left anterior mass that was confirmed on chest CT scan and MRI. Biochemical examinations and serum protein electrophoresis demonstrated hypoproteinemia (5.4 g/dl) and hypogammaglobulinemia (7.9%, 0.43 g/dl). Lymphocyte subset analysis showed OKT4 epitope deficiency (OKT4 0.1% and Leu3a 28.4%), and decrease of CD4/CD8 ratio (0.65). An encapsulated anterior mediastinal mass and the thymus were resected on January 9, 1989, without difficulty. Histology revealed a thymoma with a spindle cell epithelial component. OKT4 epitope deficiency in a patient with Good's syndrome (thymoma with hypogammaglobulinemia) was our diagnosis. There was no change in the patient's serum immunoglobulin level after thymectomy. Fifteen cases of Good's syndrome have been reported in Japan, but this is the first report of OKT4 epitope deficiency with Good's syndrome in Japan.

[Correlation between slopes of pulmonary blood flow-driving pressure curve and routine pulmonary function].

In 91 preoperative cases of lung cancer, an attempt was made to correlate the slopes of pulmonary blood flow-driving pressure curve (delta DP/delta CI), as constructed from unilateral pulmonary arterial occlusion (UPAO) test values and pulmonary blood flow fraction values as measured by scintigraphy, with total pulmonary vascular resistance index (TPVRI) and pulmonary vascular resistance index (PVRI) and routine pulmonary function. FVC and FEV per unit body surface (BSA) were found to correlate, to same degree, with delta DP/delta CI, TPVRI and PVRI (p less than 0.05). delta DP/delta CI correlated significantly with FRC/BSA, whereas TPVRI and PVRI did not. 3) The inverse of the cardiac index (1/cardiac index) was shown to significantly correlate with TPVRI and PVRI (r = 0.64, 0.48), but poorly with delta DP/delta CI (r = 0.32). These results suggest that delta DP/delta CI might possibly provide a more useful quantitative index for the pulmonary vascular bed than TPVRI and PVRI.

[Pulmonary hemodynamics during mild exercise in COPD].

The effects of mild exercise on pulmonary hemodynamics and ventilatory responses in COPD were studied. Six patients with FEV1% less than 70% received 20 watt exercise tests by cycle ergometers for 5 minutes. Changes in hemodynamics and ventilation were observed before and during exercise. Nine patients with an FEV1% of more than 70% also received exercise tests as controls. There were no different in changes in respiratory frequency, tidal volume and minute ventilation between control and COPD group. However, the mean pulmonary arterial pressure were higher in the COPD group than in the control group before exercise. Moreover increments of mean pulmonary arterial pressure by exercise were also greater in COPD group. It was concluded that hemodynamics in COPD are much more influenced by mild exercise than in healthy subjects.

[Respiratory regulations of pulmonary vagal nerves under hypercapnic conditions; effects of J-receptor].

We studied ventilatory responses under hypercapnic condition in 9 lightly anesthetized dogs, using a vagal nerve cooling technique. One side of the cervical vagosympathetic trunks of dogs were previously severed, and a copper cooler was attached to the other side. When the cervical nerve was cooled below 7 degrees C, the Hering-Breuer inflation reflex ceased. We found that when the vagal nerve was not cooled or cooled to 7 degrees C, the respiratory frequency increased significantly in relation to hypercapnic gas inhalation. However, the increment of respiratory frequency was reduced by bilateral cervical vagotomy. We concluded that the J-receptor is responsible for the increase in respiratory frequency under hypercapnic gas inhalation.

[Possible involvement of vascular endothelium-derived relaxing factor induced by platelet-activating factor (PAF) on human pulmonary artery after contraction in vitro].

We studied the effects of platelet-activating factor (PAF) on human pulmonary vascular smooth muscle in vitro. 10(-6) M PAF elicited slight contractions in 2 of 7 endothelium-denuded arterial strips, but did not elicit distinct contractions or relaxations in the other strips. After incubation with PAF at 10(-7) M, the contractions of pulmonary vascular smooth muscle induced by histamine and prostaglandin F2 alpha were significantly decreased. Preincubation of 10(-3) M indomethacin did not affect the inhibitory effects of PAF, but these disappeared with removal of endothelium. These results suggest that the inhibitory effects of PAF on human pulmonary vascular smooth muscle contractions may appear not through the cyclooxygenase products but the endothelium-derived relaxing factor.

[Pulmonary fibrosis after endotoxin-induced permeability edema].

To know the pathogenesis of the lung fibrosis after ARDS, we investigated the role of PMN-elastase after endotoxin-induced pulmonary edema in awake sheep with chronic lung lymph fistulas. The permeability of the pulmonary circulation increased 2 hours after endotoxin injection. Four hours after endotoxin injection, WBC migrated to the lung interstitium and the number of WBC in BALF increased. Endotoxin increased PMN-elastase in plasma and lymph whereas the level of alpha-1-protease inhibitor (alpha-1-PI) did not change. The activity of alpha-1-PI measured by trypsin inhibitory capacity was zero in the exudative phase. The level of PMN-elastase in lymph was significantly higher 1 week after endotoxin injection than baseline levels. Histologically, pulmonary fibrosis developed 1 week after endotoxin injection. These results suggest that inflammatory mediators released from PMN play an important part in progress to the fibrotic phase after ARDS.