Preservation of alveolar epithelial fluid transport mechanisms in rewarmed human lung after severe hypothermia.

Although hypothermia abolishes alveolar fluid clearance in the in situ goat lung and in the ex vivo human lung, it is unknown whether alveolar fluid clearance resumes in lungs that are rewarmed after severe hypothermia. An isosmolar albumin solution was instilled into resected human lungs that were rewarmed to 37 degrees C after hypothermia (7 +/- 3 degrees C), and then alveolar fluid clearance was measured by the concentration of albumin in the alveolar fluid sample after 4 h. In control experiments in lungs that had not been cooled and rewarmed, alveolar fluid clearance was 11 +/- 2% over 4 h. In separate experiments, hypothermia completely abolished alveolar fluid clearance. However, alveolar fluid clearance resumed to a normal level of 12 +/- 1% over 4 h in the lungs that were rewarmed after hypothermia. Amiloride decreased alveolar fluid clearance by 47% in the rewarmed lungs. Terbutaline increased alveolar fluid clearance by nearly 300% in 2-h experiments in the rewarmed lungs (P < 0.05). The results of this study indicate that alveolar sodium-channel transport mechanisms are preserved in resected human lungs that are exposed to rewarming after hypothermia.

Usefulness of ultrasonography in operation for pulmonary arteriovenous fistula.

A 54-year-old woman presented with nonhereditary, bilateral pulmonary arteriovenous fistulas. One of them was small (10 x 10 mm) and embedded in the parenchyma; it was neither visible nor palpable from the pleural surface. We therefore used intraoperative ultrasonography and succeeded in detecting and enucleating the small fistula with minimal resection of the normal lung tissue.

[Two cases of traumatic lung cyst].

There are few reports of traumatic lung cyst in Japan. The 1st case was 20-year-old man with traumatic lung cyst from motor vehicle accident. A chest radiograph taken 70 days after initial injury showed almost complete resolution of the traumatic pneumatocele. The 2nd case was 7-year-old girl with traumatic lung cyst caused by motor accident. The traumatic pneumatocele was not yet reduced in size four months after initial injury.

[Two cases of the congenital posterolateral diaphragmatic hernia were reported].

Case 1, a 9-year-old woman, was admitted to our hospital because of nausea, vomiting, and epigastralgia. Diagnosis of Bochdalek hernia was made by the unusual course of naso-gastric tube. At surgery through the left posterorateral thoracotomy, the herniation of the stomach, small intestine, and colon to the thoracic cavity through the dorsolateral defect of the diaphragm were revealed. Case 2, a 35-year-old man, was admitted to our hospital because of dyspnea. Similar diagnosis was made by the examination of upper G1 series and barium enema, which demonstrated the presence of multiple loops of the small intestine and colon in the left thoracic cavity. Their postoperative courses were uneventful. Most of Bochdalek hernia is observed in infancy, and adolescent or adult case is is rarely reported (approximately 10% of all cases). Since this often misdiagnosed as pleuritis or pulmonary tuberculosis, a cautious examination is necessary for the establishment of the correct diagnosis.

[An experience of surgery for thymolipoma in a patient with amyotrophic lateral sclerosis].

A 48-year-old male with amyotrophic lateral sclerosis (ALS) was revealed to have an anterior mediastinal tumor, occupying left hemithorax on a chest CT. The tumor compressed the left lower lobe, resulting in a hypoventilation, which required a continuous ventilatory support. Although ALS has poor prognosis in general, we decided to remove the tumor surgically. Because the symptoms related to ALS was limited to his extremities, indicating he could potentially reestablish his life under ventilator-free condition, when a remove of the tumor improved a hypoventilation. A remove of the tumor was performed via antero-axillar thoracotomy, and reexpansion of the left lower lobe was achieved, followed by improvement of lung function and of respiratory symptoms. Histological examination revealed that the tumor was composed of mature adipose tissue and thymic tissue, diagnosed as thymolipoma. Postoperative course was uneventful.

[Reconstruction after wide resection of the chest wall: application of plates as rigid prosthetic materials].

Wide resection of the chest wall requires reconstruction with rigid prosthetic material to protect the thoracic organs and to avoid flail chest. We tried to use three kinds of plates for chest wall reconstruction in 4 cases: acrylic plate for 1, ultra-high-molecular-weight polyethylene (UHMWP) plate for 1 and methyl metacrylic resin (MMR) plate for 2. Marlex mesh was utilized to strengthen the rebuilt chest wall sandwiching rigid prosthesis in UHMWP plate and MMR plate. Except for somewhat local accumulation of serous fluid in two cases of acrylic plate and MMR plate, postoperative courses were uneventful in all cases. Acrylic plate which was used for patient with metastatic sternal tumor was easily damaged by heat. UHMWP plate which was used for patient with large benign sternal tumor was expensive and took a long time to make. On the other hand, MMR plates which were used for two patients with malignant lateral chest wall tumor were easy to handle on the spot and not expensive. MMR plate sandwiched by Marlex mesh seems to be more suitable and available for chest wall reconstruction.

[A study of surgical treatment in lung cancer over 75 years of age-effect of epidural anesthesia for protection of postoperative coughing disturbance].

29 patients over 75 years of age in 221 patients undergoing resection of lung cancer from January of 1990 through December of 1994 were studied for the occurrence of expectoration disturbance (atelectasis), the effect of epidural anesthesia for protection of it. Atelectasis was observed in 8 (27.6%) of 29. In a group received epidural anesthesia (EA) during the early postoperative phase, 1 of 5 patients developed atelectasis. In 192 patients below 75 years of age, atelectasis was observed in 40 (20.8%) of them, so in a group received epidural anesthesia (EA) during the early postoperative phase, only 2 of 42 patients (4.8%) developed atelectasis. This value was significantly lower than that value (25.3%) in a group without EA. In conclusion, in the group below 75 years of age, EA during the early postoperative phase may be useful in inhibiting the occurrence of atelectasis, an important one of the postoperative lung complications.

[Two cases of clear cell tumor of the lung].

We report two cases of benign clear cell tumor of the lung, which were found as well-circumscribed lesions on chest X-ray films without any symptoms, and removed surgically. Light microscopy showed proliferation of clear cells filled with glycogen in both cases. Immunohistochemical examination performed in a case suggested that the tumor cells might be associated to a derivation from neural and/or smooth muscle cells, because of positive staining for NSE and SMA. In another case, the tumor formed a necrotic cavity, which could be detected by the preoperative MRI examination. This report might introduce a note of caution for the pathologic and radiographic diversity of this disease.

[Experience with surgery for metachronous double cancer originated from thymus and lung].

A case with thymic cancer who developed pulmonary cancer ten years after the initial surgery was reported. A 50-year-old man was admitted to our hospital due to SVC syndrome. Chest X-ray examinations including venogram showed a mass lesion at the superior mediastinum. The patient underwent surgical removal and reconstruction of SVC, followed by radio-chemotherapy. The histologic diagnosis was thymic squamous cell carcinoma. He was admitted to our hospital again ten years after the initial surgery under the diagnosis of pneumonia. Bronchoscopic examination revealed nodular lesions at the right upper lobe bronchus and lower lobe bronchus, those lesions were diagnosed with squamous cell carcinomas cytologically. Right pneumonectomy was performed and the diagnosis was confirmed pathologically. Postoperative course was uneventful as of 10 months after the operation. It was concluded that this case showed metachronous double cancer of the thymus and the lung, as well as synchronous multiple bronchogenic carcinomas, which, to our knowledge, has never been reported yet.

[Surgical treatment of metastatic lung tumor from colorectal cancer].

We have experienced thirty-one operations of metastatic lung tumors from colorectal cancer. Various factors affecting prognosis are studied based on 5-year survival in this report. Overall 5-year survival rate was 32%. Statistical significance was present in the relationship between the prognosis and both maximum diameter of lesions and the disease free intervals (DFI) after surgery for metastatic lesions. Though not significant, sex, stage of primary lesion, nodal involvement, surgical procedure, postoperative serum CEA were likely affecting factors on the prognosis. In contrast, there were no relationship between the prognosis and following factors: age, location of the metastatic lesion, DFI after the operation for primary lesion and chemotherapy. Although pulmonary metastasis is essentially an index of the advanced state of malignant diseases leading to poor prognosis, long-term survivors were encountered in our series of surgical treatments for pulmonary metastases from colorectal cancers. It was concluded to be important to make efforts to extend the indication for surgical treatment, since the appropriate selection of patients revealed to give excellent results from our experience of colorectal cancer. In order to improve the prognosis, early detection of pulmonary metastases is quite important, since the incidence of nodal involvement proved to be higher in lesions with larger diameter resulting in inferior survivals from the present study. In addition, low incidence of nodal involvement in small-sized lesion may support possible applicability of thoracoscopic surgery in the excision of metastatic tumors locating at peripheral lesion.

[A case of idiopathic thrombocytopenic purpura combined with lung cancer].

A 71-year-old male was admitted to our hospital because of a chest abnormal shadow. His chest X-ray film showed a mass in the right lower lobe (S6), which was diagnosed as adenocarcinoma by transbronchial lung biopsy. A lab data on the admission showed thrombocytopenia (44,000 per cu. mm), and the results of the bone marrow aspiration was compatible with idiopathic thrombocytopenic purpura. Immediately after the right lower lobectomy with lymphnode dissection, intrathoracic bleeding from the wound due to hemorrhagic tendency appeared necessitating a re-thoracotomy. High-dose intravenous gamma-globulin infusion for 4 days and the frequent concentrated platelet transfusion were employed to prevent the hemorrhagic tendency after the 2nd operation, and the postoperative hemorrhage was successfully controlled. Perioperative high-dose intravenous gamma-globulin infusion was concluded to be useful in the patient of idiopathic thrombocytopenic purpura for preventing hemorrhagic tendency after the operation.

[Castleman's disease associated rheumatoid arthritis recurring 20 years after removal].

A 40-year-old female associated with Rheumatoid Arthritis was treated by extirpation of the mediastinal tumor. Histological examination of the tumor revealed Castleman's disease of Hyaline-Vascular type and histology of the dissected mediastinal lymphnodes was the same appearance as tumor. The present case is unusual in that the tumor recurred in the same site 20 years after removal. The complete removal of tumor with dissection of lymphnodes surrounding tumor is important for the treatment of surgery. The present case is the 1st to be reported in Japan.

[Pulmonary lymphangiomyomatosis associated with spontaneous pneumothorax].

A 34-year-old female associated with spontaneous pneumothorax was diagnosed as pulmonary lymphangiomyomatosis by open lung biopsy and pathological examination. The biopsy specimen of the lung showed marked proliferation of smooth muscle in the lung. This disease is seen only in women in childbearing age, and hormonal therapy is ineffective, but bilateral oophorectomy seems, in some cases, to have a beneficial effect. Lung transplantation can be applied to patients with terminal pulmonary lymphangiomyomatosis.

Effects of hypothermia and hyperpotassium on alveolar fluid clearance in the resected human lung.

The effect of hypothermia and hyperpotassium on alveolar fluid clearance in the resected human lung was examined by instilling an isosmotic albumin solution with a potassium concentration of 0.3 mEq/l or 20 mEq/l into one segment of a resected lobe within 10 min of surgical removal for bronchogenic carcinoma. The experiments were carried out at 37 degrees C, 25 degrees C, and and 8 degrees C over 4 hr, after which the alveolar fluid was aspirated. Alveolar fluid clearance was calculated by a simple equation using the changes in the albumin concentration of the alveolar fluid. It was found that although hypothermia at 8 degrees C abolished alveolar fluid clearance completely, alveolar fluid clearance at 25 degrees C was not different from that at 37 degrees C. Moreover, although the potassium concentration increased in the alveolar fluid at 37 degrees C and 8 degrees C, hyperpotassium did not affect the alveolar fluid clearance. These findings indicate that the net transport of potassium leans to influx from the alveolar epithelial cells into the alveolar spaces when the alveolar potassium concentration is low, and to efflux from the alveolar spaces when the alveolar potassium concentration is high. Thus, we conclude that hypothermia abolishes alveolar fluid clearance in resected human lungs, but that the potassium concentration in alveolar fluid does not affect alveolar fluid clearance.

[A case of systemic origin of an aberrant artery to the basal segment of the lung].

We report on a rare case of systemic origin of an aberrant artery to the basal segment of the lung (Pryce I type intralobar pulmonary sequestration) that caused occasional bloody sputum. The patient was admitted to our hospital after an abnormal image was discovered in Chest X-ray film. The chest MRI showed an abnormal vessel originating from the descending aorta. The aortagram showed an abnormal artery originating from the descending aorta and entering the left lower lobe, and the left pulmonary angiogram revealed a poorly blood supply to the left basal segments. The preoperative diagnosis of systemic origin of an aberrant artery to the basal segment of the lung was given. The patient was subjected to surgical treatment. During surgery, it was found that the abnormal artery, 12 mm in diameter, which was connected from the descending aorta to the left basal segments. The abnormal artery was dissected, and the left basal segments was removed. The postoperative course was uneventful.

Hypothermia inhibits the alveolar epithelial injury caused by hyposmotic albumin solution during preservation of the resected human lung.

This study was conducted to determine whether hypothermia inhibited alveolar epithelial injury in the resected human lung during preservation. Hyposmotic albumin solution, 248 mOsm/kg, was instilled into the alveolar spaces of resected human lungs which were inflated with an airway pressure of 7 cmH2O and stored at either 37 degrees C or 8 degrees C for 4 h. Alveolar fluid was aspirated and the influx of lactate dehydrogenase (LDH) and globulin into the alveolar spaces, as markers of alveolar epithelial injury, was measured. Ion transport and fluid clearance across the alveolar epithelium were calculated by the changes in electrolyte and albumin concentrations in the alveolar fluid, respectively. While the LDH levels and globulin concentrations increased significantly in the hyposmotic experiments at 37 degrees C, hypothermia inhibited these increases. Alveolar fluid clearance at 37 degrees C increased to 20% in the hyposmotic experiments compared with 12% in the control isosmotic experiments; however, sodium and chloride transport in the hyposmotic experiments was not significantly different from that in the isosmotic experiments. Thus, we conclude that hypothermia at 8 degrees C inhibits alveolar epithelial injury caused by the hyposmotic solution in resected human lungs. Moreover, alveolar ion and fluid clearance mechanisms were preserved across the injured alveolar epithelial cells.

Beta-adrenergic agonist stimulated alveolar fluid clearance in ex vivo human and rat lungs.

Because beta-adrenergic agonist therapy may be useful clinically as a treatment to hasten the resolution of alveolar edema, this study was designed to examine the dose-dependent effects of beta-adrenergic agonist therapy on alveolar epithelial fluid clearance. The studies were done by instilling an isosmolar 5% albumin solution into the distal air spaces of both ex vivo rat and ex vivo human lungs that were inflated with 8 to 10 cm H2O with 100% oxygen and placed in a 37 degrees C humid incubator. Alveolar fluid clearance was measured by the progressive increase in concentration of protein over 1 or 4 h. Salmeterol, a new long-acting lipophilic agent, was more potent than terbutaline in stimulating alveolar fluid clearance from the ex vivo human lung. Therefore, salmeterol was used for these studies. The results indicated that: (1) basal, unstimulated alveolar fluid clearance in rat lungs was significantly faster than in human lungs (24 +/- 4% over 4 h in rat lungs compared with 11 +/- 2% over 4 h in human lungs, p < 0.05); (2) comparison of equivalent doses of beta-adrenergic stimulation indicated that stimulated clearance rates were also faster in rat lungs than in human lungs; (3) very low doses of salmeterol were effective in ex vivo rat lungs (10(-8) M); and (4) relatively low doses were effective in the ex vivo human lungs (10(-6) M) as a treatment for increasing alveolar fluid clearance. In summary, there are significant differences in the basal and stimulated rates of alveolar epithelial fluid clearance in rat and human lungs, although the ex vivo human studies may have underestimated maximal alveolar fluid clearance in the intact human lung. The human lung responds well to relatively low doses of beta-adrenergic agonist therapy, a finding with potentially important clinical implications for hastening the resolution of alveolar edema.

Alveolar fluid clearance in the resected human lung.

Although the mechanisms responsible for alveolar liquid clearance have been studied in several species, there has not been any information regarding the effect of ion transport agonists or antagonists on alveolar liquid clearance in the human lung. Therefore, we studied alveolar liquid clearance in the recently resected human lung from patients who underwent surgery for lung cancer. A test solution of 40 ml of isosmolar albumin solution was instilled into one segment of a resected lobe within 10 min of resection. Because protein leaves the air spaces very slowly, the concentration of alveolar protein over 4 h was used to quantify alveolar liquid clearance. Basal alveolar liquid clearance was 12 +/- 2% over 4 h. Amiloride (10(-5) M), an inhibitor of apical Na+ uptake, and ouabain (10(-3) M), an inhibitor of Na,K-ATPase activity, reduced alveolar liquid clearance by 40 and 49%, respectively (p < 0.005). Terbutaline (10(-3) or 10(-4) M) doubled alveolar liquid clearance to 28 +/- 9% over 4 h (p < 0.05). Propranolol (10(-4) M) and amiloride (10(-5) M) inhibited the terbutaline-induced increase in alveolar liquid clearance. In conclusion, (1) alveolar liquid clearance in the human lung can be markedly reduced by inhibition of apical sodium channel uptake or Na,K-ATPase activity, and (2) beta-adrenergic stimulation markedly increases the rate of alveolar liquid clearance in the resected human lung without pulmonary perfusion.