[Thoracoscopic surgery using a new bronchial blocker].

We report use of a new bronchial blocker through a single-lumen endotracheal tube to achieve one-lung ventilation to perform thoracoscopic operation in patients in whom placement of the double-lumen tube failed and difficult intubation is predicted. The bronchial blocker tube was placed into the aimed bronchus under the bronchoscopic vision and the cuff of the blocker was inflated to achieve one-lung ventilation. In all of the 4 patients, the bronchial blocker could be inserted and placed safely, quickly, and exactly under the fiberoptic flexible bronchoscopic vision to perform thoracoscopic operation without any complications. The new bronchial blocker tube through the indwelling endotracheal tube may have advantages in situations where placement of double-lumen endotracheal tubes is technically impossible or inappropriate. The use of the new bronchial blocker tube will, however, require careful evaluation in larger series.

[Thoracoscopic pericardial resections for malignant pericardial effusions].

We have performed 5 thoracoscopic pericardial resections for malignant pericardial effusions. An initial trocar was placed in the seventh or eighth intercostal space posterior to the midaxillary line. Two additional trocars were placed, usually in the sixth intercostals spaces in the anterior axillary and posterior axillary lines. Using an endoscopic grasping instrument and scissors through the working ports, a pericardial resection was performed. All patients were successfully managed by thoracoscopic pericardial resections. Two of the 5 patients had associated malignant pleural effusions that were able to be managed at the same time by thoracoscopy. The average chest tube duration was 1.8 days. There has been no reaccumulation of pericardial effusions in all patients at an average follow-up of 5 months. The thoracoscopic approach could be minimally invasive and the procedure of choice in performing pericardial resections in selected patients with malignant pericardial effusions who are expected to have a reasonable life expectancy.

[A thoracoscopic technique with fibrin glue and polyglycolic acid mesh for the injured lung during thoracoscopic operation].

The injury of the lung occurred during thoracoscopic operation, especially, of the fragile, severely emphysematous lung is often difficult to treat. A fibrin glue spraying device in which an air compressor was connected to an intravenous catheter was constructed, and connected to a Dupuloject syringe. Fibrin glue was administered by spraying on the target lesion under a thoracoscopic vision. The procedure was done while the tip of the intravenous catheter was held and manipulated with forceps through a thoracoport. And then, the polyglycolic acid (PGA) mesh that had been cut into small pieces was put on the target lesion with forceps. Fibrin glue was sprayed on the lesion again in the above-mentioned manner. When necessary, the procedure was repeated. Our technique during thoracoscopic operation may be easy to manipulate and be able to apply the target lesion uniformly within a short time with a successful repair.

[Thoracoscopic surgery for metastatic lung tumors: computed tomography-guided localization with use of a needle with a suture].

When a metastatic lung tumor is found to be deep to the visceral surface of the pleura, or when it is found to be a small lesion, it may important to help identify the lesion by preoperative methods in order to localize it at the time of thoracoscopic operation. We performed computed tomography-guided localization of metastatic lung tumors with use of a needle with a suture in 11 cases prior to thoracoscopic resection. Placement of the needle, immediately before moving to the operation room were successfully performed in all patients. It took from 16 to 25 minutes (20.3 minutes on average). Complications included minimal pneumothorax in 8 patients, mild airway bleeding in 2, and penetration through the middle lobe to the lower lobe of the right lung in 1. However, treatment was not necessary in any of the patients. Thoracoscopic resections were successfully achieved in all patients. Our technique may be a simpler technique and advantageous for identification of small lesions and lesions deep to the visceral surface of the pleura during the thoracoscopic operation for metastatic lung tumors.

[Initial use of the newly developed voice-controlled robot system for a solitary pulmonary arterio-venous malformation].

We herein report an initial experience of thoracoscopic surgery for a solitary arterior-venous malformation (PAVM) with the AESOP 3000 HR voice-controlled robot to hold a thoracoscope. A 52-year-old woman was hospitalized due to a transient loss of consciousness. A brain magnetic resonance image and electroencephalogram (EEG) were normal. A chest computed tomogram indicated a suspicion of PAVM. The definite diagnosis of the PAVM was made by the 3-dimensional computed tomogram and pulmonary angiography. Thoracoscopic operation with the voice-controlled robot (AESOP 3000 HR) was conducted. The operating staffs were able to assemble the AESOP 3000 HR robotic system safely and quickly without difficulty. The robot functioned without problems throughout the procedure. No complications or events related or unrelated to the maneuvers of the robot during the operation were noted. The procedure of the pulmonary resection with the voice-controlled robot was successfully preformed by a single surgeon. The operating time was 110 minutes, and the volume of the intraoperative bleeding was 10 g. The postoperative course was uneventful. The use of the AESOP 3000 HR robot may be more convenient and friendly in thoracoscopic procedure.

[Bronchoscopic treatment for upper tracheal lesions with a laryngeal mask].

A laryngeal mask provides maintaining airway with a larger inner diameter of the tube. A little information is available about bronchoscopic treatment for upper tracheal lesions. Three patients undergoing bronchoscopic treatment for upper tracheal lesions with a laryngeal mask were reviewed. The patients include 3 women, having 2 thyroid cancers and 1 thyroid goiter. The aims of the procedure were hemostasis and reduction of the tumor with subsequent endotracheal stenting in 2 patients, and endotracheal stenting in one patient. The treatment was performed under general anesthesia using a laryngeal mask. All cases were successfully treated without operative and postoperative complications related to the use of the laryngeal mask placement. Use of a laryngeal mask may facilitate insertion and retrieval of a flexible bronchoscope and instruments with an excellent manipulation in therapeutic bronchoscopy for subglottic and upper tracheal lesions.

[Thoracoscopic lung resection for a peripheral lung cancer by a single surgeon with a voice-controlled robot].

Thirty patients with a peripheral lung cancer underwent consecutive thoracoscopic lung resections with a voice-controlled robot between October 1998 and February 2001. The patients with a high risk such as cardio-pulmonary dysfunction or the patients aged 80 years or older were included. Patients with stage I cancer of the right lung in which lobectomy with lymph node dissection was anticipated were also included. Thirty thoracoscopic procedures were performed by a single surgeon using a voice-controlled robot. Thoracoscopic lung resection by a single surgeon with a voice-controlled robot was achieved in 27 patients. The postoperative follow-up period ranged from 3 months to 42 months. In all patients, thoracoscopic procedures without no need for a human assistant were achieved. There were no survival differences between the wedge resection group and lobectomy group, in the patients having adenocarcinoma and patients having squamous cell carcinoma, and elderly patients and young group patients. Complications related or unrelated to the maneuvers of a voice-controlled robot were not noted. Postoperative complications occurred in 4 patients (atelectasis 2, postoperative dementia 2). All of the events resolved within one week. Thoracoscopic lung resection such as wedge resection or lobectomy by a single surgeon with a voice-controlled robot may be feasible in selected patients with lung cancers. Its application must be confirmed by further studies.

[Thoracoscopic major lung resection using a newly developed instrument retraction system and a voice-controlled robot].

We report a case of thoracoscopic major lung resection using a newly-developed instrument retraction system and a voice-controlled robot for lung cancer in a 72-year-old woman. The patient was referred to our department for further examination of an abnormal shadow on chest x-ray. A chest computed tomographic scan indicated a suspicion of malignancy. Bronchoscopic brush cytology revealed a lung cancer. Thoracoscopic middle lobectomy of the right lung with dissection of the mediastinal lymphnodes was successfully performed without a human assistance with no complications. The postoperative course was uneventful. Thoracoscopic major lung resection using an instrument retraction system and a voice-controlled robot may be feasible in selected cases.

[Therapeutic bronchoscopy for stenotic lesions of central airway].

We retrospectively studied 26 patients with stenotic lesions of the central airway who had undergone bronchoscopic treatment. Thirteen of the patients had malignant tumors, and 13 had benign lesions (1 with post-tracheostomy difficulty in tube retrieval, 2 with bronchial obstruction due to granulation after bronchoplasty, 1 with bronchial stenosis due to granulation after pulmonary lobectomy, 7 with endobronchial foreign bodies, and 2 with hemoptysis). The patients ranged from 5 to 88 years of age with an average of 59.7 years. As a rule, bronchoscopic treatment was performed with endotracheal intubation up to 1993, and with laryngeal mask placement in 1994 and thereafter. Of the 26 eligible patients, 24 (92%) experienced good or excellent outcomes. Emergency bronchoscopy may be useful in treating a variety of emergency airway conditions. Use of a laryngeal mask may benefit emergency patients, including infants and children requiring a secure airway without complications.

[Small cell lung cancer with acute monocytic leukemia after combined chemotherapy including etoposide].

Small cell lung cancer (stage IIIB) developed in a 61-year-old woman. She was treated with chemotherapy in which the cumulative dose of carboplatin was 662 mg/m2 and that of etoposide was 2,000 mg/ m2, and with concurrent irradiation in which the total dose of X-rays was 44.8 Gy. The response to chemotherapy and irradiation was very good. Radiation pneumonitis developed after discharge, but it resolved after steroid therapy. Nine months after the diagnosis of lung cancer the patient was readmitted because of bleeding and leukocytosis. Acute monocytic leukemia (M5a) was diagnosed after examination of a bone-marrow aspirate. The patient was treated with chemotherapy, but she died of severe bone-marrow suppression and multiple organ failure 3 months after the diagnosis of acute monocytic leukemia. Although chromosome analysis could not be done, we strongly suspect that this leukemia was induced by etoposide, because of the clinical course.

Hypervolemic hypotension in surgical treatment of intracranial aneurysm.

Fifty cases of intracranial aneurysms were operated upon under hypervolemic hypotension. The cerebral metabolism was maintained within normal range. The dissection and clipping of the aneurysm were considerably easier, and a premature rupture of the aneurysm could be handled without difficulty. The advantages and the surgical results are discussed.

[Colloid cysts of the third ventricle --report of one operated and one autopsied case (author's transl)].

Colloid cysts of the third ventricle are considered as a relatively rate benign tumor, consituting approximately 0.5% of the whole brain tumors, but the surgical cases have rarely been reported in Japan. In this paper, two cases of colloid cyst are reported and the pathogenesis, the importance of the clinical diagnosis and dramatic results after complete extirpation was emphasized. In Case 1, a 29 year-old right handed male, who showed definite symptoms of increased intracranial pressure without lateralizing signs, was diagnosed as colloid cyst of the third ventricle, and operated on with dissecting microscope on April 20, 1973. The colloid cyst was totally removed and postoperatively V-A shunt was performed for adhesive arachnoiditis. Patient did well after surgery and has returned to the previous work. In Case 2, a 41 year-old male, who suffered from sudden onset of severe headache and bouts of frequent vomiting, was admitted to Tokyo Wome's Medical College Hospital on October 11, 1974. Right cerebral angiography revealed findings of increased intracranial pressure and third ventricle tumor was suspected. On October 13, progressively disturbed consciousness occurred. Immediate ventricular tap and continuous ventricular drainage could not regain consciousness and patient expired on October 30. In necropsy, colloid cyst to the third ventricle was found. As far as these are concerned, these cysts might be reasonably said as ventricular epithelial origin in view of the operative and histological findings. Some emphasis was also made in terms of dissecting microscope in removing this tumor, completely preserving the ventricular walls as well as the terminal veins under magnification.