[Bronchial injury due to double-lumen endobronchial tube].

A 68-years-old and 148 cm tall female with lung cancer was operated on a left lower lobectomy via posterolateral thoracotomy. A 35 Fr double-lumen endobronchial tube was smoothly inserted and the tip was placed in the left main bronchus whose position was confirmed by fiberoptic bronchoscope. After lobectomy and lymph node dissection were completed, 1-lung ventilation was terminated, the left chest cavity was filled with saline, and an air-leak test was performed. Immediately after the initiation of bilateral lung ventilation, massive air-leak was observed in the left hilar region and the saline in the chest regurgitated into the airway, and she fell into critical ventilatory insufficiency. After sucking the saline in the chest, thorough observation revealed a 3 cm-long rupture of the membranous portion of the left main bronchus. The rupture was manually occluded and ventilatory insufficiency was avoided, then the tip of the endobronchial tube was re-inserted into the right main bronchus and right single lung ventilation was initiated. The rupture was closed by a 4-0 polydioxanone (PDS) running suture with no coverage. The patient was extubated immediately after the operation. Ten days later, she had a tiny bronchial fistula, and it was cured by chest drainage only, and she discharged home on the 48th postoperative day.

[Intralobar sequestration in elderly patient; report of a case].

A 71-year-old woman who had been treated as bronchitis was diagnosed as intralobar sequestration by a computed tomography scan. She had 2 episodes of hemosputum in recent 30 years but the amounts were small and they spontaneously stopped in a day. She had an abnormal vessel from thoracic descending aorta of which diameter was 1 cm draining to the basal segment of the left lung. She was operated on a left lower lobectomy with ligation of the vessel via a thoracotomy. Postoperative course was uneventful, and she discharged home on the 9th postoperative day.

[Resected case of pulmonary arteriovenous malformation diagnosed with a brain abscess as a clinical manifestation; report of a case].

A 63-year-old female with Rendu-Osler-Weber disease had general fatigue and right hemiparesis. A computed tomography (CT) scan of her head demonstrated an enhancing cystic mass in the left frontal lobe, and it was diagnosed as a brain abscess and then drainaged. Thereafter, a pulmonary arteriovenous malformation (PAVM) identified in the left lingular segment by chest CT scan and the PAVM was resected by partial resection of the lung.

[Lobar torsion after pulmonary resection for lung cancer].

We reviewed our experience on postoperative lobar torsion. From January 1994 to December 2003, 1002 patients underwent lobectomy for lung cancer. Two (0.2%) patients with postoperative lobar torsion required surgical reintervention. The first case was that of a 79-year-old man who underwent left lower lobectomy for pulmonary adenocarcinoma. Based on the postoperative course, lobar torsion was highly suspected with progressive respiratory dysfunction and the chest X-ray showed complete opacification of the residual lobe. Rethoracotomy was performed on postoperative day 4. The left upper lobe was rotated clockwise, and completion pneumonectomy was carried out. The patient died 16 days after the second surgery because of respiratory failure due to severe pneumonia. The second case was that of a 24-year-old man with a diagnosis of metastatic lung cancer in the right upper lobe arising from pharyngeal cancer. The patient underwent right upper lobectomy and developed hemoptysis and persistent high fever. A chest computed tomography (CT) and bronchoscopy findings revealed lobar torsion of the middle lobe, and a reoperation was performed. The middle lobe was resected and the patient was discharged 8 days after the rethoracotomy. Pulmonary lobar torsion poses a difficult diagnostic dilemma in the early postoperative period after the pulmonary resection. Since late reoperation for postoperative lobar torsion sometimes results in poor prognosis, careful observation with bronchial fiberscopy as well as chest radiography is necessary for accurate diagnosis. Rethoracotomy should be carried out without any delay in cases of lobar torsion following pulmonary resection.

Relationship between anti-ABO antibody production and hemolytic anemia after minor ABO-mismatched living-donor lobar lung transplantation.

With the shortage of lung donors, we have performed 28 living donor lobar lung transplantations (LDLLTs) since October 1998. Although lungs from ABO-identical donors were used if available, lungs were transplanted from donors showing minor ABO mismatches when suitable ABO-identical donors were not found. The aim of this study was to evaluate the relationship between anti-ABO antibody (Ab) production and the outcomes of lung transplantation with ABO-mismatched living donor lungs. We reviewed 28 patients (28 recipients with 55 donors) who underwent LDLLT between October 1998 and March 2004. In this patient population, 13 patients (46.4%) received minor ABO-mismatched transplants. Anti-A or B-IgG or IgM antibodies (Abs) in the serum and red cell elutes were examined. All 28 patients are alive and well at a mean observation period of 28.0 months (ranging from 5 to 70 months). Anti-A or B-IgG or IgM Abs were detected in 5 out of 13 minor ABO-mismatched patients (38.5%) after transplantation, but only one of them showed evidence of severe hemolytic anemia due to donor-derived antibodies. The titer of that patient's Abs was higher than that of the other recipients. Anti-ABO antibody production and anemia were not associated with gender, age, relationship between donors and recipients, and HLA matching. We conclude that LDLLT across ABO mismatches is an acceptable treatment for end-stage lung disease.

[Penetrating chest trauma in which thoracoscopy was helpful; report of a case].

A 32-year-old builder suffered from a chest trauma in a construction area. A ratchet penetrated his right chest wall posterolaterally, and he was transferred to our hospital. A chest X-ray and a computed tomography (CT) revealed that the tip of the instrument remained in the thoracic cavity and there were no other obvious damages including pneumothorax, hemothorax, and liver damage. We thought the simple removal of the instrument from his body was dangerous so he was transferred to the operating room and his chest was opened under general anesthesia. However, it was difficult to confirm the inside of penetrating point from the thoracotomy wound; therefore we used a thoracoscope. The thoracoscopy disclosed a penetration in the lung and a contusion on the diaphragm. The application of thoracoscopy in the operation of thoracic trauma is very promising in exploration of the thoracic cavity, especially in the area which is out of vision from the open thoracotomy.

Experimental study of oversized grafts in a canine living-donor lobar lung transplantation model.

BACKGROUND: For infants and small children, organ transplantation is limited by the size discrepancy between donor and recipient. To address this problem, the use of over-sized grafts from living-relative donors could potentially expand the donor pool. The aim of this experimental study was to evaluate the effect of oversized grafts on early pulmonary function and to identify an indicator for acceptable size discrepancy. METHODS: Fourteen bilateral lobar lung allotransplant operations were performed without cardiopulmonary bypass in weight mismatched pairs of dogs. Animals were divided into 2 groups: Group I (n = 7), donor/recipient lung volume ratio < 2.85; Group II (n = 7), donor/recipient lung volume ratio >2.85. Pulmonary function of the recipient was measured before chest closure, after chest closure, and after the ventilator was removed. RESULTS: Pulmonary vascular resistance and airway pressure significantly increased in Group II after chest closure (1493 +/- 195 dynes sec cm(-5) and 14.4 +/- 0.9 mm Hg vs 2784 +/- 140 dynes sec cm(-5) and 23.4 +/- 1.2 mm Hg, p < 0.001). After the ventilator was removed, all recipients in Group I showed PaO2 > 239 mm Hg and PaCO2 < 76 mm Hg, whereas, all recipients in Group II showed PaO2 < 116 mm Hg and PaCO2 > 169 mm Hg. The donor/recipient chest circumference ratio was less than 1.3 in all but 1 dog in Group I. CONCLUSIONS: Acceptable, oversized grafts provide adequate pulmonary function, although excessively oversized grafts cause significant impairment in pulmonary function after chest closure. Chest circumference provides useful size-match criteria when oversized grafts are used in this canine experimental model.

Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure.

BACKGROUND: Although lobectomy by the video-assisted thoracic surgical (VATS) approach is assumed to be less invasive than lobectomy by the standard posterolateral thoracotomy (PLT) approach, it has not been scientifically proven. METHODS: Twenty-two consecutive, nonrandomized patients, underwent either a VATS approach (n = 13) or a posterolateral thoracotomy approach (n = 9) to perform pulmonary lobectomy for peripheral lung cancers in clinical stage I. Pain and serum cytokines were measured until postoperative day (POD) 14. Pulmonary function tests were performed on POD 7 and POD 14. RESULTS: Postoperative pain was significantly less in the VATS group on PODs 0, 1, 7, and 14. Recovery of pulmonary function was statistically better in the VATS group. Negative correlations between the recovery rates of pulmonary function and postoperative pain were observed on POD 7. The serum interleukin-6 level in the PLT group was significantly elevated on POD 0 compared with the VATS group (posterolateral thoracotomy: 21.6+/-24.3 pg/mL; VATS: 4.1+/-7.9 pg/mL, p = 0.03). CONCLUSIONS: Lobectomy by the VATS approach generates less pain and cytokine production, and preserves better pulmonary function in the early postoperative phase.

Living-donor lobar lung transplantation for primary ciliary dyskinesia.

A ventilator-dependent patient with primary ciliary dyskinesia underwent successful living-donor lobar lung transplantation. The case was a 24-year-old woman who had developed recurrent lower respiratory infection and became ventilator-dependent due to severe bronchiectasis. Transmission electron microscopy of the resected bronchus demonstrated inner dynein arm deficiency.

[Two cases of advanced and metastatic breast cancers treated by docetaxel in combination with intra-arterial infusion of adriamycin].

Two cases of advanced and metastatic breast cancers were treated by docetaxel (TXT) in combination with intra-arterial infusion of adriamycin (ADM). Patients received 60 mg/body TXT i.v. and 30 mg/body ADM ia (AT therapy) bi-weekly. Clinical responses were observed in these two patients and the durations of responses were over 20 weeks. Critical toxicities of grade 2 leukopenia and alopecia were observed but grade 4 severe toxicities were not. Thus AT therapy can be easily and safely performed with outpatients. This therapy can improve the response rate and time to progression; therefore phase I or phase I/II clinical trials of AT therapy in Japan are recommended.

Intrapulmonary lymph nodes enlarged after lobectomy for lung cancer.

A 62-year-old man, who had had a left upper lobectomy for mucoepidermoid lung carcinoma, was admitted again 3 months later because of enlargement of four small nodules in the left lower lobe. A computed tomography-guided needle aspiration biopsy obtained insufficient material for diagnosis, and because pulmonary metastases were suspected, two of the four tumors were extirpated. Intraoperative frozen section found the nodules to be intrapulmonary lymph nodes. Intrapulmonary lymph nodes should be included in the differential diagnosis of coin lesions in the peripheral lung field.

Referrals for lung transplantation in Japan. Unique indications and necessity of living-donor lobar lung transplantation.

OBJECTIVES: The purpose of this study was to review all referrals to our lung transplant program and to find realistic options for accepted candidates in Japan. METHODS: During the period from April 1992 to August 1999, 45 referrals were received. After screening, 22 of the referred patients were admitted for an extensive inpatient evaluation, and 15 of these were accepted as candidates for transplantation. RESULTS: The indication was primary pulmonary hypertension in 9, bronchiectasis in 2, lymphangioleiomyomatosis in 2, idiopathic pulmonary fibrosis in 1, and pneumoconiosis in the other 1. Two of those with primary pulmonary hypertension went to the USA and there received bilateral lung transplant. One with bronchiectasis received living-donor lobar lung transplantation in our center. These three recipients are alive and doing well during the follow-up period of 11 to 69 months. Among the 12 patients who have not received lung transplant, 5 patients have died while waiting. CONCLUSIONS: Indications for lung transplant are quite distinct in Japan, and primary pulmonary hypertension is the most frequent indication. Living-donor lobar lung transplantation is a realistic option for properly selected candidates.

[Three cases of pulmonary mucoepidermoid carcinoma].

Three cases of pulmonary mucoepidermoid carcinoma, which were surgically treated in our hospital, were reported. The first case was 28-year-old male, who had hemoptysis, underwent right upper lobectomy and mediastinal lymph node dissection on October 31, 1973. The tumor located and obstructed the ostium of right B2. The diameter was 2.3 x 1.8 cm. The second case was 63-year-old male, who had obstructive pneumonia, underwent left upper lobectomy and mediastinal lymph node dissection on November 18, 1998. The tumor located and obstructed the ostium of lingular bronchus, and the diameter was 1.8 x 1.2 cm. The third case was 25-year-old male, who had obstructive pneumonia, underwent left sleeve lower lobectomy and mediastinal lymph node dissection on May 26, 1999. The tumor located in ostium of left B6, and it obstructed lower bronchus and expanded into the lung. The diameter was 4 x 2 cm. All cases were diagnosed as low grade malignancy with no lymph node metastasis. The first case survived without recurrence at least 5 years as far as we followed, and the others are surviving until now without any signs of recurrence. These three cases were 0.19% of total resected lung cancers in our hospital from 1969 to 1999.

Toxicity of cationic liposome-DNA complex in lung isografts.

BACKGROUND: Cationic lipids have been successfully employed as vectors for gene transfer in lung grafts, yet those lipid vectors have potential toxicity. Furthermore, the optimal concentration of cationic lipids for gene transfection to lung grafts has not been determined. We evaluated liposome concentration/toxicity relationships in an in vivo rat lung transplantation model. METHODS: Left lungs were harvested and infused via the pulmonary artery with chloramphenicol acetyl-transferase (CAT)-DNA/lipid 67 (cationic lipid)/dioleoylphosphatidylethanolamine complex (4:1:2 in a final concentration ratio). Donor lungs were allocated into six groups according to lipid 67 concentration: group 1, 0 microM (control); group 2, 10 microM; group 3, 50 microM; group 4, 100 microM; group 5, 250 microM; group 6, 500 microM. Forty-eight hours after orthotopic transplantation, the recipient contralateral right main pulmonary artery and bronchus were ligated. The graft was ventilated with 100% oxygen for 5 min. Arterial blood gas analysis (PaO2, PaCO2), peak airway pressure (PAP), and CAT activity of the grafts were measured. RESULTS: Recipient survival, and PaO2, PAP, and CAT levels correlated with the lipid-DNA complex concentration. The grafts in groups 4-6 were more injured as evidenced by decreased PaO2 and increased PAP levels in comparison to the control group. CAT level was significantly lower in group 2 than in groups 3-6. CONCLUSIONS: The pulmonary toxicity of cationic lipid is dose-dependent. The balance between lung graft function and transgene expression is optimal at a lipid 67 concentration of 50 microM.

[Two cases of thymic carcinoma effectively treated by preoperative chemotherapy].

A 67-year-old man was admitted with left pleural effusion on chest X-ray film. Chest CT scans showed an anterior mediastinal tumor, left pleural dissemination and pleural effusion. Percutaneous needle biopsy yielded a diagnosis of epitherial carcinoma. The patient underwent 3 courses of systemic chemotherapy (CDDP + ADM + VCR + CPA). At achievement of partial response, the tumor was completely resected. Examination of the resected tumor revealed partial response to chemotherapy. A 49-year-old woman was admitted our hospital with supraclavicular lymph nodes swelling. Chest CT scans showed an large mediastinal tumor. Percutaneous needle biopsy yielded a diagnosis of squamous cell carcinoma of thymus. The patient underwent 3 courses of systemic chemotherapy. At achievement of partial response, the tumor was completely resected. Examination of the resected tumor revealed partial response to chemotherapy. These cases indicate the usefulness of preoperative chemotherapy for advanced thymic carcinoma to reduce tumor size and to control local invasion, distant metastasis before operation.

Effects of inhaled nitric oxide in a canine living-donor lobar lung transplant model.

OBJECTIVE: In living-donor lobar lung transplantation, early severe graft dysfunction can occur if the size or amount of transplanted lung tissue is insufficient. The purpose of this study was to evaluate the effects of inhaled nitric oxide on early pulmonary function in a canine bilateral living-donor lobar lung transplant model. METHODS: Sixteen pairs of mongrel dogs with a donor/recipient weight ratio less than 1.2 were used. The donor lung bloc was extirpated after heparinization. Right middle, lower and cardiac lobes were implanted as a right lung of the recipient and left lower lobe was implanted as a left lung without cardiopulmonary bypass. In Group 1 (n = 9), nitric oxide gas was administered continuously at a concentration of 40 parts per million prior to reperfusion of the right lung throughout the 6-hour assessment period after transplantation. In Group 2 (n = 7), nitrogen gas was administered in the same manner as nitric oxide, for control. RESULTS: At the end of assessment, the survival rate was 89% (8/9) in Group 1 and 57% (4/7) in Group 2. The arterial oxygen tension in Group 1 was significantly higher than that in Group 2. The pulmonary arterial pressure and pulmonary vascular resistance index were significantly lower in Group 1 than in Group 2. The aortic pressure and cardiac index did not differ significantly between the two groups. The wet-to-dry weight ratio and myeloperoxidase activity were significantly lower in Group 1 than in Group 2. CONCLUSIONS: These data suggested that inhaled nitric oxide improved early pulmonary function in living-donor lobar lung transplantation by vasodilatating the pulmonary vasculature and inhibiting neutrophil activation.

Inhaled nitric oxide ameliorates postoperative acute graft dysfunction after living-donor lobar lung transplantation.

Inhaled nitric oxide, a selective pulmonary vasodilator, decreases mean pulmonary artery pressure and pulmonary vascular resistance and improves oxygenation in previously unobtainable ways without significant changes in systemic hemodynamics. We report successful treatment of a patient with acute graft dysfunction after living-donor lobar lung transplantation using nitric oxide inhalation.

Ex vivo transfection of pulmonary artery segments in lung isografts.

BACKGROUND: Gene transfer to lung grafts may be useful in ameliorating ischemia-reperfusion injury and rejection. Proximal pulmonary artery endothelial transfection may provide beneficial downstream effects on the whole lung graft. We have already demonstrated the feasibility of in vivo and ex vivo transfection in proximal pulmonary artery segments of rat lung grafts. The aim of this study was to determine the optimal conditions for and duration of transfection. METHODS: Orthotopic left lung transplantation was performed in F344 rats after donor lung proximal pulmonary artery segments were isolated and injected with lipid 67/DOPE-chloramphenicol acetyl transferase (CAT) complementary deoxyribonucleic acid construct. Effect of exposure time was studied by exposing donor pulmonary artery segments to the construct for 0, 30, and 60 minutes prior to transplantation. In another series of experiments, pulmonary artery segments were exposed to the construct for 60 minutes prior to transplantation. Onset and duration of gene expression were determined after sacrificing animals at 3, 6, 12, and 24 hours and 3 days as well as 1 week, 2, 4, and 8 weeks after transplantation. Effect of exposure temperature was studied by exposing pulmonary artery segments to the construct for 60 minutes at 4 degrees, 10 degrees, and 23 degrees C. These recipients were sacrificed on postoperative day 3. Effect of exposure pressure was studied by using two volumes of the construct (0.01 and 0.03 mL). These recipients were sacrificed on postoperative day 3. Transgene expression was assessed by chloramphenicol acetyl transferase activity assay. RESULTS: Transgene expression was similar after 30- and 60-minute exposure. Transgene expression was evident within 3 to 6 hours after operation and persisted at 8 weeks after operation. Expression was detected at all temperatures and was equivalent at both exposure pressures. CONCLUSIONS: Gene transfection into graft pulmonary artery segments is possible under a range of conditions applicable to clinical lung transplantation.