[Video assisted thoracic surgery for the treatment of catamenial pneumothorax].

Video assisted thoracic surgery (VATS) was applied in 3 cases of pneumothorax combined with pathologic changes in the diaphragm (two cases of catamenial pneumothorax and one case of suspected catamenial pneumothorax). Case 1, 39-year-old woman, was preoperatively diagnosed as catamenial pneumothorax in the right lung. Thoracoscope was inserted through the 5th intercostal anterior axillary line and the lesion with the pathologic changes in the central tendon of the diaphragm was incised and sutured with Endo-GIA and Endo-STAPELAR. Case 2, 42-year-old woman, was confirmed to have pathologic changes in the central tendon after insertion of thoracoscope through the 5th intercostal anterior axillary line. Minithoracotomy of 50 mm in size was added close to the center of the diaphragm and direct incision and suture of that part were performed. Case 3, 47-year-old woman, underwent thoracoscopy through the 5th intercostal mid-axillary line and bulla in the S2 interlobar surface was incised with Endo-GIA. In this case, the diaphragm was partially incised through additional minithoracotomy because some lesions were detected on that part. VATS can fully be carried out for pathologic changes in the diaphragm in catamenial pneumothorax. Since catamenial pneumothorax may be complicated with another pathologic changes in the diaphragm (Case 1) or in the visceral pleura (Case 3), the whole thoracic cavity, including diaphragm and visceral pleura, should be carefully observed under thoracoscopy. Application of minithoracotomy-associated thoracoscopic surgery is a useful method in the case to whom catamenial pneumothorax is definite or suspected.

[Concomitant cardiac and pulmonary operation, the profits of not using cardio-pulmonary bypass].

We performed off pump CABG (coronary artery bypass grafting) and right upper lobectomy with R2a lymph nodes dissection on the patient suffered from both lung cancer in the right S1 and stenotic lesion in the left anterior descending artery. Because the coronary lesion was long-segmented one, it was not suitable for percutaneous transluminal coronary angioplasty. To perform absolutely curative operation for the lung cancer, CABG was undergone simultaneously under off pump condition. It is generally feared that the cardiovascular surgery under CPB may have adverse effect for the patient with malignant lesion. Off pump CABG is expected to avoid such disadvantage of CPB, and thought to be suitable method for such a patient as we present above.

Changes in immune-endocrine response after surgery.

The authors evaluated the relationship between hormonal and cytokine responses after surgery. Patients who underwent thoracic oesophagectomy (O group; n = 7), pulmonary lobectomy (P group; n = 5), modified mastectomy (M group; n = 5) and laparoscopic cholecystectomy (LC group; n = 7), were randomly selected. Circulating neutrophil and lymphocyte numbers were assayed. Changes in the concentration of the hormones [adrenocorticotrophic hormone (ACTH), cortisol, and antidiuretic hormone (ADH)] and cytokines [tumour necrosis factor alpha (TNF-alpha), interleukin 1 beta (IL-1 beta), IL-6, and IL-10] were analysed. In O and P groups, neutrophils were still seen on post-operative day (POD) 3, while the leukocyte counts of M and LC groups returned to normal. The number of lymphocytes significantly decreased on POD1 and POD3 only after oesophagectomy. The pattern of hormonal levels was consistent in all groups. While TNF-alpha and IL-1 beta were undetectable in the peripheral blood, the concentration of IL-6 and IL-10 increased in O and P groups, but not in M and LC groups. The degree of lymphocytepenia and neutrophilia correlated well with the extent of surgical trauma.

[A case of supramediastinal neurinoma: its operative approach (via supraclavicular route) and radiographic findings (target sign)].

A 76-year-old female with supramediastinal tumor was admitted. CT scan showed central high density area surrounded by low density area and MR imaging emphasized the same concentric circle. This concentric circle pattern on CT scan and MR imaging is called "Target sign", which is known as characteristic radiographic finding of neurinoma. Therefore we could diagnose her case as mediastinal neurinoma preoperatively. She underwent operation through the supraclavicular approach and the tumor was completely resected. By incising the skin through the modified left hemi-collar incisional line and cutting the clavicula at its central part, we could ensure a good operative field and safely performed this operation without mid-sternotomy or thoracotomy. The supraclavicular approach for the operation of supramediastinal tumor is useful.

[A case of a patient with post-operative empyema due to Mycobacterium chelonae].

We reported a case of a thoracic empyema due to M. chelonae (Atypical Mycobacterium, group IV) after thoracic surgery. A 49-year-old male underwent right middle lobectomy for pulmonary metastasis of esophageal cancer. Postoperative course was complicated for intractable air leakage, and several procedures were tried before successful re-thoractomy. Seven days after re-thoractomy, mycobacterium was proved in pleural effusion. And later on M. chelonae was identified by DNA hybridization method. Therefore, open window thoracotomy was performed at once. M. chelonae disappeared 7 days after operation and the patient discharged on 40 postoperative days. Thoracic empyema by M. chelonae is rare, and only one case was reported in Japan so far. Present case was not combined with infectious pulmonary disease by some mycobacterium. Therefore it is most reasonable to suppose this intrathoracic infection developed through the thoracic drain. In conclusion, because of the M. chelonae toleranced for almost all anti-biotics including anti-tuberculous agents, except clarithromycin, the timing of surgical approach is important for the treatment of this infectious disease.

[Sleeve pulmonary arterial resection for bronchogenic carcinoma].

Two cases of bronchogenic carcinoma undergone left upper lobectomy (R 3) with bronchoplasty and sleeve pulmonary arterial resection via mid-sternotomy were reported. Both cases were squamous cell carcinoma originated in the orifice of the left upper lobe. Case 1 was stage IIIB (T2N3M0) bronchogenic carcinoma, its postoperative course was uneventful and died of distant lymphatic metastasis thirty-three months after operation. Case 2 was stage II (T2N1M0) bronchogenic carcinoma and its postoperative management was laborious because of hard expectoration of the sputum but is doing well fifteen months after operation. In order to preserve adequate pulmonary function and to maintain reasonable quality of life (QOL) for the patients with impaired pulmonary function, this angioplastic procedure seems to be acceptable. It is still under discussion to perform this procedure for the patients who would be able to withstand undergoing pneumonectomy, therefore we adopt this method only for every patient for whom it is difficult to maintain desirable QOL after pneumonectomy. Namely, for the patient whose predicted one second forced expiratory volume (FEV1.0) after pneumonectomy is less than 900 ml/m2, we'll be likely to try this angioplastic procedure at first.

[Catamenial pneumothorax with diaphragmatic and visceral plural endometriosis].

A 47-year-old woman was admitted to our hospital because of two episodes of right pneumothorax. After continuous suction through a thoracic drain, a computerized tomographic scan showed that air was still trapped between lung lobes. Video-assisted thoracic surgery revealed a bulla on the visceral pleural of the upper lobe (S2) and several dark-red spots and white-coated lesions surrounding a defect of the diaphragm. The involved portions of the diaphragm and of the lung were excised. Microscopic examination of the excised specimens showed endometriosis. Catamenial pneumothorax may be caused by intrathoracic endometriosis, but very few cases in which pulmonary or visceral pleural endometriosis was demonstrated histologically have been reported.

[Successful resection and repair of the superior vena cava and right atrium in a patient with invasive thymoma].

A 45-year-old female, who suffered from Superior Vena Cava (SVC) syndrome, was diagnosed as invasive thymoma by means of trans-sternal aspiration cytology (TSAC). After preoperative radiotherapy and two courses of neoadjuvant chemotherapy, she underwent radical tumor resection combined with partial resection of both SVC and the right atrium followed by pericardial patch repair under the cardiopulmonary bypass. Complete resection is the most important procedure for the therapy of invasive thymoma, even if the tumor is in advanced stage invading to large vessels such as SVC. As far as our knowledges are concerned, complete resection of invasive thymoma combined with partial resection of the right atrium is very rare. Our case shows that partial resection of the right atrium is not risky operative procedure, if the invaded lesion of the right atrial wall is localized at the antero-lateral side to which the sinus node and the conducting system is not close. And we chose pericardial patch repair for the large defect of SVC. This patch repair was good method in this case because the blood flow through the Azygos vein was well maintained. We would also like to emphasize that TSAC is useful diagnostic procedure for the mediastinal mass lesion to which transcutaneous aspiration using the ultrasound or CT scan as a guide is impossible.

[Extended extrapleural pneumonectomy by median approach for advanced malignant mesothelioma with right supraclavicular lymph node metastasis--a case report].

A 52-year-old woman of diffuse malignant mesothelioma of the right pleura with metastasis to right supraclavicular lymph nodes underwent extended extrapleural right pneumonectomy and neck dissection. For this resection we selected the new approach: median sternotomy with hemi-collar incision. Through this approach systematical dissection of the cervical-mediastinal lymph nodes was performed together with resection of the right lung, parietal pleura, the pericardium and the diaphragm. As a result of this en bloc resection, she is alive without recurrence for one year after the operation.

[A successful case of omentopexy for bronchopleural fistula and empyema after right pneumonectomy].

A 59-year-old male was performed right pneumonectomy with R 2 b lymph node dissection and intercostal muscle flap to the bronchial stump for squamous cell carcinoma of right upper lobe of the lung (cT 2 N 2 M 0-stage III A). But four weeks later bronchial stump was suddenly reopened and he developed empyema. Omentopexy for bronchopleural fistula (15 x 11 mm in size) and thoracoplasty for empyema was performed. Bronchoscopically the fistula is 2 mm in diameter and reepithelization is started around the fistula at 14 POD and the fistula is completely closed and covered with reepithelized mucosa without inflammation at 100 POD. We think omentopexy for bronchopleural fistula after pneumonectomy is very effective procedure, so we should be considered this method at first. But if the fistula is accompanying empyema as our case thoracoplasty should be added.

[The necessity of extended systemic dissection of the regional lymph node in radical operation for lung cancer].

Since 1979, 109 patients underwent bilateral mediastinal lymph node dissection through a median sternotomy as a routine procedure in the treatment of left lung cancer, because of the high possibility of contralateral mediastinal node involvement in cases of left lung cancer. The five-year survival rates of the initial 50 patients who underwent this operation from Oct. 1979 till Mar. 1988 were 76.5% in N0 (n = 17), 69.2% in N1 (n = 13), 50.0% in N2 (n = 10) and 20.0% in N3 (n = 10). The five-year survival rate of 7 patients with pT1-2 N2M0 disease was 71.4%. This survival rate was only slightly different from that of the pT1-2N0-1M0 group. From May 1985 till April 1993, 20 patients who had the cervical or the highest mediastinal lymph node involvement underwent cervical and bilateral mediastinal lymph node dissection through a cervical collar incision and median sternotomy. Two patients with the scalene node involvement (one each of right and left lung cancer) are surviving for five years or more after surgery. Extended ipsilateral mediastinal lymph node dissection (R2b) has been adopted as a routine procedure in the treatment of right lung cancer in our institute since 1990. The survival rate at forty months in 15 patients with N2 disease who underwent R2b operation was 51%. In 3 of these fifteen patients the anterior mediastinal lymph node metastases were revealed by post-operative pathological investigation.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of re-expansion pulmonary edema following water seal drainage for spontaneous pneumothorax--management with right and left-separated mechanical ventilation].

A 23-year-old male with complete collapse of the right lung due to spontaneous pneumothorax was admitted 11 days after its onset. Paying close attention to the re-expansion pulmonary edema (REPE), water seal drainage was performed. Following couple episodes of persistent severe cough, four hours later, he developed dyspnea and began to expectorate frothy massive sputum. Chest X-ray revealed pulmonary edema of the entire right lung field. Measurement of total proteins and neutrophil elastase in airway exudates showed 5.5 g/dl (ratio to plasma, 0.89) and 7000 micrograms/l, respectively. Because of marked difference of compliance between bilateral lungs, management with right and left-separated mechanical ventilation and PEEP applied only to the right lung was performed. Although transient mediastinal deviation to the left was observed, successful management was achieved by the maneuver. High concentrations of total proteins and neutrophil elastase in edema fluid suggest that increased vascular permeability due to endothelial cell injury via activated neutrophils is mainly responsible for REPE. In the present case, rapid expansion of the collapsed lung accelerated by severe cough seems to be a predisposing factor of REPE. In patient with prolonged pneumothorax, suppression of cough is thought to be important for the prevention of REPE even with water seal drainage.

[A case of simultaneous operation for ischemic heart disease and lung cancer].

A case of 76-year-old man had a coin lesion in the chest roentgenogram, which rapidly grew with central necrosis, and chest pain at rest. Squamous cell carcinoma was concluded from transbronchial lung biopsy for that lesion. Coronary angiography revealed long segment occlusion of the left anterior descending which was not a candidate for percutaneous transluminal coronary angioplasty and 90% stenosis of the left circumflex coronary artery. Aorto-coronary bypass grafting and right upper lobectomy via midsternotomy, was simultaneously performed. the postoperative course was fair and there was no cardiac complication. A simultaneous operation is more preferable in selected cases.