[Successful Pulmonary Embolectomy using a Bronchoscope:Report of a Case].

Surgical pulmonary embolectomy is indicated for acute massive pulmonary thromboembolism complicated by floating thrombi in the right heart system. Postoperative residual thrombi are associated with persistent pulmonary hypertension and subsequent right heart failure, resulting in poor surgical outcome. A 67-year-old man was admitted to our institution owing to dyspnea on exertion. Transthoracic echocardiography revealed a floating right atrial mass and right ventricular overload. In addition, enhanced computed tomography (CT) showed a right atrial mass as well as bilateral massive pulmonary embolism. We performed an urgent pulmonary embolectomy using a bronchoscope as an adjunctive angioscope to completely remove the peripheral thrombi and to prevent serious complications, such as endobronchial hemorrhage due to pulmonary arterial injury. A clear, bloodless view of peripheral pulmonary arteries was obtained using short intermittent circulatory arrest technique. Postoperative course was uneventful, and he was discharged ambulatory 20 days after the surgery without any symptoms.

Chest tightness is relieved with the use of asthma drugs except bronchodilators.

Objective: Many patients with a chief complaint of chest tightness are examined in medical facilities, and a lack of diagnosis is not uncommon. We have reported that these patients often include those with chest tightness relieved with bronchodilator use (CTRB) and those with chest tightness relieved with the use of asthma drugs except bronchodilators (CTRAEB). The purpose of this study was to demonstrate the clinical characteristics of the patients with CTRAEB and compare them with data from patients with CTRB. Methods: Patients with CTRB (n = 13) and CTRAEB (n = 7) underwent a bronchodilator test, assessments of airway responsiveness to methacholine, bronchial biopsy, and bronchial lavage under fiberoptic bronchoscopy before receiving treatment. In all, 10 healthy subjects, 11 bronchial biopsy control patients, and 10 asthmatic patients were recruited for comparison. Results: Inhalation of a short-acting ß2-agonist (SABA) increased the forced expiratory volume in one second (FEV1) by 5.1% ± 4.0% in patients with CTRB and by 1.3% ± 3.5% in patients with CTRAEB, and the difference was statistically significant (p = 0.0449). The bronchial biopsy specimens from the patients with CTRB and CTRAEB exhibited significant increases in T cells (p < .05) compared with those of the control subjects. The bronchial responsiveness to methacholine was increased in only a minor portion of patients with CTRB and CTRAEB. Conclusions: We hypothesized that the clinical condition of patients with CTRAEB involves chest tightness arising from inflammation alone, and this chest tightness is mostly associated with airway T cells, without constriction of the airways. There is little to distinguish CTRAEB from CTRB aside from the response to bronchodilator treatment. This clinical trial is registered at www.umin.ac.jp (UMIN13994, 13998, and 16741).

Bronchial biopsy and reactivity in patients with chest tightness relieved with bronchodilator.

OBJECTIVE: It has been hypothesized that some patients with chest tightness of unknown origin can be successfully treated with a bronchodilator and that they should be diagnosed with chest pain variant asthma. We conducted a prospective study to characterize newly diagnosed patients with chest tightness relieved with bronchodilator use and without characteristic bronchial asthma attacks. METHODS: Eleven patients were registered following recurrent positive responses of chest tightness to inhalation of a ß2-agonist. These patients underwent assessments of airway responsiveness to methacholine, bronchial biopsy and bronchial lavage under fiber-optic bronchoscopy before receiving treatment. RESULTS: For the patients with chest tightness relieved with bronchodilator use, the bronchial biopsy specimens exhibited significant increases in lymphocyte and macrophage infiltration (p < 0.05) and no significant increase in eosinophils (p = 0.2918) compared with the control subjects. The bronchial responsiveness to methacholine was increased in two of the patients with chest tightness, and it was not increased in seven; in addition, increased percentages of eosinophils were detected in bronchial lavage fluid (5% or more) from two patients, but no increase was detected in eight patients. CONCLUSIONS: We suspect that the chest tightness was induced by airway constriction in these patients, but further study is necessary to validate this hypothesis. We propose that the chest tightness relieved with bronchodilator use was attributed to airway constriction resulting from inflammation with lymphocytes and macrophages and/or that the chest tightness was directly attributed to airway inflammation. This clinical trial is registered at www.umin.ac.jp (UMIN13994 and UMIN 16741).

Talc slurry pleurodesis in patients with secondary intractable pneumothorax: A phase 2 study.

BACKGROUND: Secondary pneumothorax, which occurs most commonly in the elderly, is caused by underlying diseases. Cardiac dysfunction and other organ inefficiencies may render surgical repair impossible. Such non-operative and poor-risk cases are targets for pleurodesis, which involves the instillation of chemicals or irritants to the thoracic cavity through injection, bronchoscopic bronchial occlusion, or other procedures. Sterile graded talc has been used for pleurodesis mainly in Europe and the United States; however, only a few studies and case series investigating this topic have been published. This study evaluates the efficacy and safety of talc slurry pleurodesis. METHODS: Patients with inoperable secondary intractable pneumothorax, who were not candidates for surgical repair, were recruited. Four grams of sterilized talc was suspended in 50 mL of physiological saline and injected through a tube into the pleural cavity. Additional 50 mL of saline was subsequently injected through the same channel to clean the residual saline in the injection tube. Another additional talc instillation was allowed to control persistent air leakage. The primary endpoint was the proportion of drainage tube removal within 30 days after talc pleurodesis. RESULTS: Thirty-one patients were included in this study. In 23 out of 28 patients, the drainage tube could be removed within 30 days of talc instillation (82.1 %, 95 % CI = 63.1-93.9), exceeding the threshold of 36.0 % (p < 0.0001). The most common event was pain (11/28 patients, 39.3 %). CONCLUSIONS: Talc slurry pleurodesis is effective for intractable secondary pneumothorax, with minor side effects.

[Cardiac angiosarcoma resected after definitive diagnosis by thoracoscope-assisted biopsy].

A 31-year-old woman presented with cardiac tamponade. Contrast-enhanced chest computed tomography(CT) revealed an inhomogeneously-enhanced soft tissue mass measuring 50×35×30 mm, which was in contact with the right atrial wall. The mass was definitely diagnosed as cardiac angiosarcoma by thoracoscope-assisted biopsy. The right atrial wall, including the tumor, was extensively resected, and then reconstructed with the equine pericardium. Postoperative radiation therapy was performed, but the patient developed malignant ascites with an intra-pericardial ectopic tumor recurrence. Additional radiation therapy was performed, but she died 177 days after the operation. Although thoracoscopeassisted biopsy is considered to be a useful diagnostic method for cardiac tumors on the surface of the heart, it carries the risk of spreading tumor cells. In the present case, the tumor should have been resected immediately after the prompt pathological diagnosis.

A case of giant intradiaphragmatic bronchogenic cyst.

We present the case of a giant bronchogenic cyst (BC) that appeared just within the right diaphragm. A 51-year-old man was referred to our hospital with a chief complaint of pain from the lumbar area to the right shoulder. Computed tomography images showed a cystic mass measuring 18.0 × 17.5 × 12.8 cm in the right thoracic cavity. Right posterolateral thoracotomy from the eighth intercostal space was performed, and the cyst wall and diaphragm were resected together. The defect of the diaphragm was repaired using a 2-mm-thick Gore-Tex™ expanded polytetrafluoroethylene patch. It is embryologically rare for a giant BC to develop within the right diaphragm. As BCs may be associated with malignant tumours or infection, complete resection of the cyst wall is required. Literature review revealed no consensus on the best surgical procedure. Therefore, it is important to consider the appropriate surgical procedure for each case.

[A case of idiopathic pulmonary alveolar proteinosis with multiple localized ground-glass opacities].

A 58-year-old Japanese female consulted our staff with multiple localized ground-glass opacities in chest CT. She underwent video assisted thoracoscopic surgery for diagnosis. Histopathologic finding from surgery specimen in one of ground-glass opacities revealed bronchioloalveolar carcinoma. Six months later, we performed second video assisted thoracoscopic surgery, and histopathologic finding of all other ground-glass opacities revealed pulmonary alveolar proteinosis. Serum anti GM-CSF antibody elevated, and she was diagnosed as having idiopathic pulmonary alveolar proteinosis. A case of idiopathic pulmonary alveolar proteinosis presenting multiple localized ground-glass opacities is rare. And, differentiating ground-glass opacities of pulmonary alveolar proteinosis and bronchioloalveolar carcinoma by chest CT is difficult.

Multiple Metastasizing Pleomorphic Adenomas of the Lung.

A 40-year-old woman was referred to our hospital with abnormal findings on chest X-ray. Her medical history was remarkable in that she had presented with a pleomorphic adenoma in the right parotid gland treated by surgical removal approximately 12 years previously. Chest computed tomography showed well-defined non-calcified nodules of the bilateral lobes, so she underwent segmentectomy of the right upper lobe and middle lobe. The histopathological diagnosis was metastasizing pleomorphic adenoma of the lung, a rare entity.

Retrospective analysis on prognostic impact of adjuvant chemotherapy in the patients with advanced and resectable oral squamous cell carcinoma.

PURPOSE: The effect of adjuvant chemotherapy on oral squamous cell carcinoma (SCC) is unclear mainly because there have been a few studies which evaluate the efficacy of adjuvant chemotherapy. The purpose of this retrospective study was to analyze the efficacy of adjuvant chemotherapy in the patients with advanced and resectable oral SCC. METHODS: 41 patients in whom advanced SCC (stage III and IV) was completely removed were included in this study. The impact of multiple variables including T-classification, degree of differentiation, mode of invasion, number and level of cervical metastatic node, pre-and post-operative radiation therapy, neoadjuvant chemotherapy, and adjuvant chemotherapy on survival and control of local relapse or distant metastasis was assessed using the stepwise Cox proportional hazards model. RESULTS: The level of neck node metastasis (p<0.02) was a significant independent predictor for cause-specific survival and adjuvant chemotherapy was of borderline significance (p=0.07). The number of neck node metastasis (p<0.01) and adjuvant chemotherapy (p<0.01) were significantly related with disease free survival. CONCLUSION: The results of this retrospective study suggested that adjuvant chemotherapy had a significant benefit in improving disease free survival.

[Case of allergic bronchopulmonary aspergillosis triggered by relocation of residence].

A 22-year-old woman has been treated with inhaled corticosteroid for bronchial asthma. Her family moved house to Toyama prefecture in March 2003, and she was enrolled in our hospital. Her chest radiograph on first medical examination showed the right upper lobe infiltration. Bronchoscopy revealed a mucoid impaction at right B2, and Aspergillus fumigatus was cultured from suctioning of pulmonary secretions. Histopathologic findings from transbronchial biopsy revealed eosinophilic pneumonitis but not Aspergillus fumigatus. She was diagnosed allergic bronchopulmonary aspergillosis, and she was started on prednisolone 40 mg/day. The finding of her chest radiograph improved in two weeks. This case suggested that allergic bronchopulmonary aspergillosis was triggered by moving house with exposure of Aspergillus fumigatus. We should give guidance to asthmatics to wear a dust respirator at work in dust-laden environment.

[A case of hypersensitivity pneumonitis caused by Lyophyllum karst].

A 52-year-old woman who has worked at factory to check pack Lyophyllum karst for six years consulted another doctor for dry cough as common cold. After a month, low grade fever, dyspnea on effort, and productive cough brought her to our hospital. Her chest radiographs showed multiple small nodular shadows and ground glass opacities in entire lung fields. Histopathological examination of transbronchial lung biopsy specimen revealed granuloma and thickening of alveolar septa with lymphocytes infiltration. She was admitted to our hospital for hypersensitivity pneumonitis and prescribed predonisorone 30 mg/day. Her symptoms and the finding of chest radiograph improved in two weeks. The precipitation antibodies to Lyophyllum karst were positive and the symptoms exacerbated by going to work. Those finding suggests that hypersensitivity pneumonitis in this case. After quitting her job, she has had no relapse by tapering steroids.

[Diffuse alveolar damage after inhalation of zinc oxide fumes].

A 57-year-old man with a 37-year occupational history of welding was admitted for high fever and dyspnea after inhalation of zinc oxide fumes during a period of welding without a protective mask. Chest radiography and CT showed bilateral diffuse ground-glass opacities, and blood gas analysis revealed that PaO2 was 48.1 torr in room air. A transbronchial lung biopsy was done, and revealed diffuse alveolar damage. We diagnosed the case as chemical pneumonia due to the inhalation of zinc oxide, and prescribed prednisolone 40 mg per day. As a result, his symptoms improved within several days. The inhalation of zinc oxide fume usually causes metal fume fever, but chemical pneumonia is also reported on rare occasions. As far as our examination of the literature has disclosed, this is the first report of diffuse alveolar damage after inhalation of zinc oxide fume.

[X-ray-negative endobronchial tuberculosis with persistent irritating cough that resulted in unpredicted mass infection].

A 24-year-old woman was referred to another hospital because of a barking cough, but her chest radiograph showed no abnormality. Although she had been diagnosed as having other diseases and had been given medical treatment, the barking cough continued. Abnormalities of the chest radiograph appeared 11 months later, and endobronchial tuberculosis was diagnosed from the clinical history, chest CT and a sputum smear positive for acid-fast bacilli. We treated her with INH, RFP, EB for 6 months, and PZA for 2 months. However, truncus intermedius became obstructed nine months after treatment ended, and we re-opened it with a Dumon stent after coring it out using a rigid bronchoscope. Since the patient was a teacher, medical checkups of many people were required, and the number of prophylactic treatments carried out was 80. This was regarded as a mass infection. In the early stages, endobronchial tuberculosis may not show any abnormality on chest radiography, but may still cause mass infection. When a barking cough continues for a long time, endobronchial tuberculosis must be suspected, and examination of a sputum smear for acid-fast bacilli, as well as a sputum culture is necessary.

[Central diabetes insipidus caused by pituitary metastasis of lung cancer].

A 53-year-old man admitted for thirst, polyposia, and polyuria. Large cell lung cancer T3N2M1 (Stage IV), and central diabetes insipidus caused by pituitary metastasis of lung cancer, were diagnosed. We gave him desmopressin acetate, and chemotherapy with paclitaxel and carboplatin. But pituitary metastasis increased and invaded the hypothalamus. After irradiation of the pituitary and hypothalamus, metastatic focus diminished and desmopressin acetate was tapered.

[Hypopituitarism caused by hypothalamic metastasis of lung cancer].

A 40-year-old man was admitted due to thirst, general malaise, and swollen cervical lymph nodes. Cervical lymph node biopsy revealed moderately differentiated adenocarcinoma, and he was diagnosed lung cancer with hypothalamic metastasis. We gave him chemotherapy and hypothalamic irradiation. He had mild hydrodipsia at the first examination, which progressively worsened. He was given a diagnosis of diabetes insipidus caused by hypothalamic metastasis. We gave him desmopressin acetate, and his symptom improved. Predonisolone was prescribed, because of low levels of adrenocorticotropic hormone in the blood. After chemotherapy and irradiation of hypothalamus, metastatic focus diminished and desmopressin acetate was tapered. Hypopituitarism caused by hypothalamic metastasis is rare.

[Pulmonary septic emboli in a patient with right-side infectious endocarditis].

An 18-year-old woman afflicted with ventricular septal defect was admitted for high fever and dyspnea. She had undergone no surgical repair. Chest CT showed numerous nodular opacities in both lungs. The majority of them were situated on the pleura. Echocardiography revealed an area of vegetation 20 mm in diameter just beneath the tricuspid valve. Staphylococcus aureus was cultured from venous blood. We diagnosed right-side bacterial infectious endocarditis caused by Staphylococcus aureus and culminating in septic pulmonary emboli. Intravenous panipenem/betamiprom was prescribed, and after 5 weeks, the patient recovered, was negative for C-reactive protein and had a negative venous blood culture. Cardiac septal defect with bacterial endocarditis is a major risk factor in the development of septic pulmonary emboli.

Comparison of imaging follow-up between joints with arthroscopic surgery (lysis and lavage) and those with nonsurgical treatment.

PURPOSE: To assess the influence of arthroscopic surgery on radiographically evident degenerative change of the temporomandibular joint (TMJ). The post-treatment course was compared between the joints that underwent arthroscopic lysis and lavage and those that underwent nonsurgical treatment. PATIENTS AND METHODS: Twenty-eight patients agreed to imaging follow-up examination of 35 joints. Twenty-four joints of 19 patients underwent only nonsurgical treatment (nonsurgical joints). Eleven joints of 9 patients failed the nonsurgical treatment and consequently underwent arthroscopic lysis and lavage (arthroscopic joints). The joints were assessed at first visit and at least 20 months later (mean, 79 months) for disc displacement, disc position, disc morphology, disc mobility, condylar morphology, morphology of the articular eminence, and horizontal condylar angle and size. Thereafter, interval change was assessed and compared between the groups. RESULTS: There was no significant difference in the prevalence of the progressive degenerative changes between the groups. In addition, there was no significant difference in the change of size and morphology of the condyle. However, a higher prevalence of improvement of disc mobility in the arthroscopic joints rather than the nonsurgical joints was significant (Goodness of fit test for chi(2), P < .05). CONCLUSIONS: The results of this study suggest that the post-treatment course of radiographically evident degenerative change was not significantly different between arthroscopy and nonsurgical treatment; however, arthroscopic surgery showed a greater ability to improve disc mobility. In imaging follow-up, arthroscopic lysis and lavage is a minimally invasive treatment modality that is equivalent to nonsurgical treatment.

Laryngotracheal application of lidocaine spray increases the incidence of postoperative sore throat after total intravenous anesthesia.

PURPOSE: To determine the effect of laryngotracheal application of different doses of lidocaine spray on postoperative sore throat and hoarseness, we evaluated the incidence and severity of these complications in 168 ASA I-III patients aged 15-92 years in a placebo-controlled study. METHODS: After induction of anesthesia with propofol, ketamine, fentanyl, and vecuronium, the laryngotracheal area was sprayed immediately before intubation with lidocaine spray either 5 times (L5 group, n = 47) or 10 times (L10 group, n = 48) or with normal saline 1 ml (placebo group, n = 51). Postoperative sore throat and hoarseness were evaluated immediately after surgery and on the day after surgery. RESULTS: The incidence of sore throat was significantly higher in the L10 group than in the placebo group on both the day of and the day after surgery. The severity of sore throat was significantly higher in the L5 and L10 groups than in the placebo group on the day of surgery. On the day after surgery, the severity of sore throat remained significantly higher in the L10 group than in the placebo group. Although the incidence and severity of sore throat increased in a dose-dependent manner, these were not significantly different between the L5 and L10 groups. In addition, the incidence and severity of hoarseness did not differ at all among the three groups. CONCLUSION: We recommend that applications of lidocaine spray to the laryngotracheal area should be avoided to help eliminate unnecessary postoperative sore throat, thereby leading to improvement in patient satisfaction.