Tracheal stenosis caused by unnoticed foreign bodies.

We describe an extremely rare case of tracheal stenosis caused by unnoticed microscopic fiber-like foreign bodies. A 66-year-old woman complained of dyspnea with inspiratory stridor. Magnifying electroendoscopy and computed tomography revealed stenosis involving the entire circumference of the tracheal lumen. Tracheotomy and biopsy were performed. Histologically, the lesion showed chronic inflammation with a deposition of fiber-like foreign bodies. The patient had no history of trauma or inhalation injury, but had undergone intratracheal intubation on 4 occasions. The lesion was incised using semiconductor laser photoresection, and the postoperative course was good. To the best of our knowledge, this represents the first report in the English literature of tracheal stenosis caused by unnoticed foreign bodies. The origin of these fiber-like foreign bodies remains unclear but might be related to chronic inflammation resulting from intratracheal intubations.

[A case of drug-induced eosinophilic pneumonia due to tegafur-uracil(UFT®)].

A 68-year-old female received a left lower lobectomy for lung cancer (adenocarcinoma, pT2N1M0, stage II B). She had a postoperative bronchial fistula that was treated conservatively and cured. Two months after the operation, tegafur-uracil (UFT) 300 mg/day was initiated.She felt dyspnea on exertion after taking UFT for two weeks, and some infiltration shadows were observed on a chest X-ray two weeks later. A chest CT scan revealed unsegmental infiltration shadows at the intermediate areas of the right middle and lower lobes, and an air-bronchogram was observed inside of the shadows. A bronchoscopy was performed. Bronchoalveolar lavage revealed a high fraction rate of eosinophil(24%), and a transbronchial lung biopsy revealed infiltrations of lymphocytes, eosinophils and neutrophils into the intra-alveolar space. However, fibrosis of the alveolar wall was not observed. A drug-induced lymphocyte stimulation test was performed for UFT, resulting positive. She was diagnosed as drug-induced eosinopilic pneumonia due to UFT. After she discontinued UFT and started 30 mg/day of prednisolone, dyspnea and infiltrations on chest X-ray disappeared.

[Pulmonary mucosa-associated lymphoid tissue (MALT) lymphoma accompanied with cystic change].

A 64-year-old male with throat discomfort visited our hospital, and a chest computed tomography (CT) scan revealed a cystic lesion with a central solid component in the right lung (in the lower lobe, 4.1 x 3.9 cm in diameter). Transbronchial lung biopsy was performed and the lesion was diagnosed as mucosa-associated lymphoid tissue (MALT) lymphoma of the lung. No other lymphoma lesion was detected and it was diagnosed as the stage I-E, and a right lower lobectomy was performed. The cystic lesion derived from alveolus and bronchus destroyed by lymphoma infiltration and it might be caused by air retention due to check-valve mechanism.

Experimental orthotopic lung transplantation model in rats with cold storage.

This report describes a new experimental procedure, a rat unilateral, orthotopic lung transplantation with cold storage, and evaluates its relevancy and reliability to study the early events during cold ischemia/reperfusion (I/R) injury. This model, using the cuff technique, does not require extensive training and is relatively easy to be established. The model can induce reproducible degrees of pulmonary graft injury including impaired gas exchange, proinflammatory cytokine upregulation, or inflammatory infiltrates, depending on the preservation time. The results are consistent with the previous clinical evidence, thus suggesting that this model is a valid and reliable animal model of cold I/R injury.

Optimal temperature of graft preservation after ex vivo gene transfer in lung isografts.

The aim of this study was to determine the optimal temperature of graft preservation after ex vivo gene transfer to rat lung isografts. Left lungs were harvested and infused with cationic lipid/LacZ-DNA complex via the pulmonary artery, and the grafts were stored for 4h. The grafts (n7) were allocated into groups I-IV according to the storage temperature:4, 10, 16, and 23, respectively. Forty-eight h after orthotopic transplantation, the arterial blood gas was analyzed and the peak airway pressure (PAP) and the level of LacZ protein production in the grafts were measured by reverse transcription polymerase chain reaction. After reperfusion, the grafts were stained with hematoxylin and eosin. The grafts in groups III and IV showed more deterioration as evidenced by decreased arterial oxygen tension, increased PAP, and predominant infiltration of inflammatory cells compared with groups I and II. The level of LacZ production was significantly lower in group I than in groups II-IV. The optimal temperature of lung graft preservation after ex vivo gene transfer was determined to be 10, balancing considerations of lung injury and efficiency of transgene expression.

[A case of advanced breast cancer leading to DIC after chemotherapy].

We reported a case of DIC who was administered FEC90 (5-FU 1,000 mg/body, epirubicin 170 mg/body, cyclophosphamide 1,000 mg/body) for advanced breast cancer. A 55-year-old woman was referred to our hospital with lumbago. There was a huge tumor in her left breast (10x10 cm) and bone scintigraphy showed multiple bone metastasis, so she was treated with FEC90. Before the third course, DIC occurred. The patient was then treated with FOY and heparin, and the DIC was resolved. We think the DIC of this case was related with tumor lysis syndrome. Febrile neutropenia has been occasionally emphasized during chemotherapy, but due care must be taken for lymphocyte depletion during treatment.

Addition of a neutrophil elastase inhibitor to the organ flushing solution decreases lung reperfusion injury in rat lung transplantation.

BACKGROUND: Neutrophil elastase plays an important role in ischemia-reperfusion injury. We hypothesized that the addition of sivelestat, a specific neutrophil elastase inhibitor, to the organ flushing solution would decrease reperfusion injury in a rat single left-lung transplant model. METHODS: All donor lungs were flushed with 25 ml low-potassium dextran-glucose solution and stored for 16 h at 4 degrees C. Rats were divided into three experimental groups (n=10) that received donor lungs washed in either normal flushing solution (group 1), or flushing solution containing 20mg sivelestat (group 2) or 40 mg sivelestat (group 3). Graft function was assessed 48 h after reperfusion using five measurements: isolated graft oxygenation, wet/dry ratio, peak airway pressure, tissue myeloperoxidase activity, and serum lipid peroxides level. Histological examination of lung grafts was also performed. RESULTS: Group 3 showed better oxygenation (groups 1, 2, and 3: 133.9+/-113.5, 254.0+/-84.6, and 378.7+/-77.6 mmHg, respectively; p<0.0001 vs group 1, p=0.0052 vs group 2), lower peak airway pressure (groups 1, 2, and 3: 28.7+/-6.1, 26.0+/-5.8, and 21.5+/-5.3 mmHg, respectively; p=0.0385 vs group 1), lower wet/dry ratio (groups 1, 2, and 3: 6.74+/-0.78, 5.77+/-0.52, and 4.90+/-0.16, respectively; p=0.0010 vs group 1), and lower myeloperoxidase activity (groups 1, 2, and 3: 0.304+/-0.081, 0.178+/-0.053, and 0.106+/-0.029 DeltaOD/mg/min, respectively; p<0.0001 vs group 1, p=0.0319 vs group 2). No significant differences in arterial PaCO(2) and serum lipid peroxide levels were observed between the three groups. CONCLUSIONS: Addition of sivelestat to the organ flushing solution ameliorated ischemia-reperfusion injury in a lung transplant model.

Venous velocity of the right femoral vein decreases in the right lateral decubitus position compared to the supine position: a cause of postoperative pulmonary embolism?

The right lateral decubitus position is a risk factor for postoperative pulmonary embolism. We examined postural changes of femoral vein velocity in order to elucidate the mechanism. Thirty patients scheduled for general thoracic surgery were enrolled in this study. The common femoral veins on both sides were examined by color-duplex ultrasound for venous caliber and velocity when the patients were in the right lateral, left lateral, and supine positions. The maximum diameters of the right femoral vein in the right lateral decubitus position and the left femoral vein in the left decubitus position were significantly larger than those in the other positions. The venous velocity of the right femoral vein in the right lateral decubitus position was significantly smaller than that in the supine position, while the velocity of the left femoral vein in the left lateral decubitus position was not significantly decreased. We speculate that the decreased venous velocity of the right femoral vein in the right lateral decubitus position could result in a deep venous thromboembolism in the right leg, making this position a possible risk factor for postoperative pulmonary embolism.

Bronchopleural fistula after lobectomy for lung cancer.

Bronchopleural fistula after lung resection is a fatal complication. The aim of this study was to determine the risk factors for bronchopleural fistula after lobectomy for lung cancer. Clinical records of 767 patients who underwent lobectomy or bilobectomy for lung cancer in our institution were reviewed. Twelve patients (1.6%) suffered a bronchopleural fistula, of whom 5 died because of this complication (mortality rate, 41.7%). Multivariate analysis revealed squamous cell carcinoma, preoperative chemotherapy, lower lobectomy, and middle and lower lobectomy were risk factors for bronchopleural fistula. In such cases, particular care must be exercised to maintain blood flow through the bronchial stump during surgery, and reinforcement, such as stump coverage, must be employed.

[Flail chest rescued by mechanicalventilation with early tracheotomy and physiotherapy; report of a case].

A 73-year-old man hit his fore-chest accidentally when he rode his motorcycle. A huge flail chest was observed on his central fore-chest, and multiple fractures of costal cartilage were suspected. He developed pneumonia on the 4th hospital day, and he was intubated and mechanical ventilation was initiated. Because frequent sputum aspiration was necessary and aggressive physiotherapy was desirable, a tracheotomy was performed on the same day of intubation. He recovered from respiratory failure with conservative therapy and the mechanical ventilation was disconnected 13 days later. Tracheotomy in the early phase of respiratory failure with flail chest was very effective and the surgical fixation of flail segment would not be necessary even in the case of 'stove-in chest' like the present case.

Optimal time for post-mortem heparinization in canine lung transplantation with non-heart-beating donors.

BACKGROUND: We previously reported that post-mortem heparinization by closed-chest cardiac massage is beneficial in lung transplantation from non-heart-beating donors by preventing formation of microthrombi. In this study, we evaluated the optimal time for post-mortem heparinization in canine lung transplantation from non-heart-beating donors. METHODS: Left lung transplantation was performed in 25 weight-matched pairs of mongrel dogs. Donors were killed with an intravenous injection of potassium chloride and left at room temperature for 2 hours. The cadaver donors were assigned randomly to one of five study groups. In Group H0, heparin sodium (1,000 U/kg) was given intravenously before cardiac arrest. In Groups H10, H30, H45 and H60, heparin sodium (1,000 U/kg) was given intravenously 10, 30, 45 and 60 minutes after cardiac arrest, respectively, followed by closed-chest cardiac massage for 2 minutes. After 2 hours of cardiac arrest, donor lungs were flushed with low-potassium dextran glucose solution and preserved for 60 minutes. After left lung allotransplantation, the right pulmonary artery was ligated, and recipient animals were followed up for 3 hours. Uni- and multivariate repeat analyses were utilized for statistical assessment. RESULTS: After transplantation, gas exchange was significantly worse in Groups H45 and H60 than in Groups H0, H10 and H30. Thrombin/anti-thrombin III complex concentration during warm ischemia was significantly higher in Groups H30, H45 and H60 than in Groups H0 and H10. CONCLUSIONS: The optimal time for post-mortem heparinization in lung transplantation from non-heart-beating donors is approximately 30 minutes after cardiac arrest.

Transintestinal systemic oxygenation using perfluorocarbon.

PURPOSE: Perfluorocarbons have an excellent oxygen- and carbon dioxide-carrying capacity. This prompted us to investigate the feasibility of transintestinal systemic oxygenation using perfluorocarbon. METHODS: A rat hypoventilation model (room air, 20 breaths/min and a tidal volume of 10 ml/kg) was thus established, and FC-77 (Sumitomo-3M, Osaka, Japan) was used as a perfusate. Oxygenated FC-77 was perfused through the small intestine for 4 h. The rats were allocated into three groups as follows. Group 1 (n = 6): hypoventilation only; Group 2 (n = 6): saline was perfused instead of FC-77; Group 3 (n = 6): FC-77 was perfused. Arterial blood samples were drawn from the common iliac artery every 30 min until the end of perfusion. A standard blood gas analysis was performed. RESULTS: The PaO2 level in Group 3 was significantly higher than in Groups 1 or 2 (P = 0.006: at the end of perfusion, Group 1 = 58.6 +/- 14.5 mmHg, Group 2 = 65.2 +/- 29.4 mmHg, Group 3 = 84.0 +/- 35.5 mmHg). The PaCO2 level in Group 3 was significantly lower than that in Groups 1 or 2 (P = 0.014: at the end of perfusion, Group 1 = 56.8 +/- 8.5 mmHg, Group 2 = 52.6 +/- 5.7 mmHg, Group 3 = 44.4 +/- 11.1 mmHg). CONCLUSION: Our findings indicate that transintestinal systemic oxygenation is indeed possible and could therefore become a useful new modality for respiratory assist.

Transintestinal oxygenation with perfluorocarbon: investigation of perfusion rate.

OBJECTIVE: Perfluorocarbons are structurally similar to hydrocarbons but with the hydrogen atoms replaced by fluorine. In general, perfluorocarbons have an excellent oxygen and carbon dioxide carrying capacity. We studied the suitability of oxygenated perfluorocarbon as an agent for transintestinal oxygenation and measured its perfusion rates under different conditions. SUBJECTS AND METHODS: We used FC-77 (Sumitomo 3M, Tokyo, Japan) perfluorocarbon and a rat hypoventilation model (room air, 20 breaths/min, a tidal volume of 10 ml/kg). Oxygenated FC-77 was perfused through the small intestine for 4 hours. Rats were allocated to 3 experimental groups according to the perfusion rate and a control group: Group 1 (n=6), 10 ml/min; Group 2 (n=6), 2.5 ml/min; Group 3 (n=6), 0.75 ml/min; Group 4 (n=6) served as a control (hypoventilation only). Arterial blood samples were drawn every 30 minutes. Standard blood gas analysis was performed. RESULTS: After four hours of perfusion, the PaO2 levels in Groups 1 to 3 were significantly better than Group 4 (p<0.01, Group 1: 141.7 +/- 18.0 mmHg, Group 2: 145.2 +/- 25.1 mmHg, Group 3: 120.5 +/- 21.2 mmHg, Group 4: 67.4 +/- 7.2 mmHg). PaCO2 levels in Groups 1 and 2 were significantly better than Groups 3 and 4 (p<0.01, Group 1: 42.6 +/- 7.2 mmHg, Group 2: 52.1 +/- 7.7 mmHg, Group 3: 78.2 +/- 22.8 mmHg, Group 4: 75.3 +/- 10.3 mmHg). CONCLUSION: In the present settings, 8 ml/kg/min was adequate for oxygenation and CO2 clearance. This approach promises to become another modality for respiratory assistance.

A subacute hypoxic model using a pig.

PURPOSE: A large animal model of hypoxia is necessary to develop a new therapeutic method for respiratory failure. METHODS: The experiments were performed on six pigs weighing from 15 to 19 kg. Under general anesthesia the left chest was opened and the left main bronchus was closed by a stapler. A Swan-Ganz catheter was inserted through the right jugular vein. The right carotid artery was cannulated and the mean arterial blood pressure was monitored, and arterial blood samples were drawn every 24 h until 96 h after the operation. The blood samples were submitted for a blood gas analysis. All data were expressed as the mean +/- standard deviation of the mean. RESULTS: The partial pressure of the oxygen of the arterial blood at baseline (104.8 +/- 24.3 mmHg) significantly decreased at 24 h after closure of the bronchus (76.7 +/- 9.9 mmHg, P < 0.001) and thereafter remained at the same level for 4 days. CONCLUSION: This hypoxic model using a pig was found to be very simple, effective, and reproducible. This model can be used for a variety of experiments to evaluate new therapeutic modalities for respiratory failure.

Living-donor lobar lung transplantation for bronchiolitis obliterans after bone marrow transplantation.

We report a successful case of living-donor lobar lung transplantation (LDLLT) for severe bronchiolitis obliterans (BO) after bone marrow transplantation (BMT). The patient is a 29-year-old woman who underwent BMT because of aplastic anemia in 1995. In 1996, BO developed in the patient because of chronic graft-versus-host disease. In May 2000, a LDLLT was performed. Pulmonary function tests showed improvement of both vital capacity and forced expiratory volume in 1 second. At present, 91 months after BMT and 38 months after lung transplantation, the patient is in good health. LDLLT may offer a therapeutic option for the treatment of BO after BMT.

Effects of postmortem heparinization in canine lung transplantation with non-heart-beating donors.

OBJECTIVE: Microthrombus formation appears to be one of the major detrimental factors in lung transplantation from non-heart-beating donors. The purpose of this study was to evaluate the effects of postmortem heparinization by closed-chest cardiac massage in a canine model of left single-lung allotransplantation from non-heart-beating donors. METHODS: Left lung transplantation was performed in 18 weight-matched pairs of mongrel dogs. Donors were killed with an intravenous injection of potassium chloride and left at room temperature for 2 hours. The cadaveric donors were assigned randomly to one of the three groups. In group 1 (n = 6), no heparin was given as a control. In group 2 (n = 6), heparin sodium (1000 U/kg) was administered intravenously before cardiac arrest. In group 3 (n = 6), heparin sodium (1000 U/kg) was administered intravenously 10 minutes after death, then closed-chest cardiac massage was performed for 2 minutes. After 2 hours of cardiac arrest, donor lungs were flushed with low-potassium dextran-glucose solution and preserved for 60 minutes. After left lung transplantation, the right pulmonary artery was ligated, and recipient animals were followed up for 3 hours. Univariate and multivariate repeated analyses were used for statistics. RESULTS: Both groups 2 and 3 had significantly better gas exchange and lower pulmonary vascular resistance than group 1. Changes in thrombin-antithrombin III complex concentration during the warm ischemia indicated that postmortem heparinization suppressed clotting activation in the donor. CONCLUSIONS: Postmortem heparinization by cardiac massage is beneficial in lung transplantation from non-heart beating donors by preventing microthrombus formation.

Improved survival after living-donor lobar lung transplantation.

OBJECTIVE: Survival after living-donor lobar lung transplantation has been reported to be similar to that after cadaveric lung transplantation. The purpose of this study was to summarize our 5-year experience of living-donor lobar lung transplantation for critically ill patients. METHODS: Between October 1998 and April 2004, we performed living-donor lobar lung transplantation in 30 critically ill patients with various lung diseases, including 5 (17%) patients on a ventilator. Mean age was 30.4 years (range, 8-55 years). Postoperative management included slow weaning from a ventilator, relatively low-dose immunosuppressants, and careful rejection monitoring on the basis of radiographic and clinical findings without transbronchial lung biopsy. RESULTS: The average duration of mechanical ventilation was 15.4 days, intensive care unit stay was 23.5 days, and hospital stay was 64.6 days. Clinically judged acute rejection occurred at an average rate of 1.5 episodes per patient, but infection occurred in only one patient during the first month. In spite of the complicated postoperative course, all patients were discharged without oxygen inhalation. Four patients had unilateral bronchiolitis obliterans syndrome, but the decrease in their forced expiratory volume in 1 second values stopped within 9 months. All 30 recipients are currently alive, with a follow-up period of 1 to 66 months. All donors have returned to their previous lifestyles. CONCLUSIONS: Living-donor lobar lung transplantation can be applied to both pediatric and adult patients with very limited life expectancies. It might provide better survival than conventional cadaveric lung transplantation.

Relation of epidermal growth factor receptor, phosphorylated-Akt, and hypoxia-inducible factor-1alpha in non-small cell lung cancers.

The role of the epidermal growth factor receptor (EGFR)/Posphorylated-Akt (P-Akt) signaling axis in regulating hypoxia-inducible factor-1alpha (HIF-1alpha) expression in vivo is not well understood and is of potential clinical importance since the extent of hypoxia in the tumor environment is thought to be an important determination of resistance to chemotherapy and radiotherapy. We performed the immunohistochemical studies in 80 patients with non-small cell lung cancers to evaluate EGFR, P-Akt, and HIF-1alpha expression. Significant correlation between P-Akt and HIF-1alpha (P=0.0006) and marginal correlation between EGFR and P-Akt (P=0.066) were found. P-Akt was shown to be a poor prognostic factor as to patients with lymph node involvement (P=0.031).

[Benign mediastinal tumors].

Most of benign mediastinal tumors are asymptomatic; however, sometimes we encounter emergent cases. In this article we discuss with regard to the situation that benign mediastinal tumors with severe symptoms need to be treated emergently. Any benign mediastinal tumors can cause respiratory and cardiac failure as they grow large enough to compress surrounding structures. It is very unique that the symptoms are relieved or worsen according to the patients' position. Rupture of mature teratoma is another situation which necessitates emergent therapy. The symptoms due to rupture depends on the site, that is pericardial space, intrapulmonary, and thoracic cavity. The mechanism of rupture is suspected to autolysis, infection, and necrosis of the tumor. Anesthesia is an important issue in treating such huge mediastinal tumors, because general anesthesia using muscle relaxants can introduce acute respiratory or cardiac failure. Patient's position is again very important, for example, in the patients with orthopnea anesthesia is sometimes initiated and the patient is intubated in sitting position. Although it is rare, we must be aware of these emergent situations when we treat patients with benign mediastinal tumors.