[Esophago-bronchial fistula confirmed with bronchoscopy utilized an indocyanine green].

The patient was a 54-year-old female with both headache and vomit presented to the emergency room. Endoscopic examination revealed an advanced esophageal cancer located on the middle thoracic esophagus. Histological analysis revealed squamous cell carcinoma. The clinical stage was diagnosed as T4N2M0 and this case was treated by the chemoradiation. She presented progressive moist cough after chemoradiotherapy. Esophagography demonstrated esophago-bronchial fistula (EBF). EBF was not detected by routine broncoscopy. To confirm fistula, we were performed the bronchoscopy which utilized an indocyanine green. Contrast media colored green were over from the superior segmental bronchus in a bronchoscope. The bronchoscope which utilized an indocyanine green is effective for EBF.

[New forceps for a sutureless patch technique using sheet materials].

Intraoperative air leaks are often treated by a sutureless patch technique using a fibrin tissue-adhesive collagen fleece or synthetic materials with fibrin sealant. Intraoperatively, the technique of using these materials has been troublesome, therefore air leaks fail to close. Akicette has been applied as an easy sutureless patch technique for air leaks. Seven air leaks (5 were lung cancers, 2 were spontaneous pneumothorax) were treated with Akicette. Akicette is simple to operate with, and can easily carry sheet materials. Using Akicette, the sheet materials tightly adhered onto surrounding the pleural defect without any sliding on the wet lung surface. Akicette is feasible tool for a sutureless patch technique and is useful to easily place the sheet materials.

[Surgical management of acute empyema].

Basic principles apply to the management of all forms of acute empyema: investigation and treatment of the underlying infection, drainage of purulent collection, obliteration of the space, and treatment of the associated intercurrent medical conditions. From July 1999 to May 2001, we performed surgical treatment in 11 patients for acute empyema. There were 4 cases of the fibrinopurulent phase and 7 cases of the organizing phase. Surgical procedure was 7 open thoracotomies and 4 thoracoscopies. The mean operating time was 154.2 +/- 36.6 minutes and blood loss during surgery was 344.7 +/- 274.8 ml. There was no procedure-related morbidity. In conclusion, early aggressive surgical approach is a feasible method for treatment of acute empyema.

[Corrective surgery for pectus excavatum in patients with Marfan syndrome].

OBJECTIVE: Among 1,967 patients who underwent corrective surgery for pectus excavatum in our department between January 1980 and December 2001, 33 patients diagnosed as having Marfan syndrome were evaluated. We evaluated the clinical problems and outcome of the 33 patients. RESULTS: The outcome of corrective surgery for pectus excavatum in the 26 patients who underwent a single technique surgery was generally good. Pectus excavatum was complicated by a total of 25 cases of cardiovascular disorder in 14 of 33 (42%) patients. Six patients underwent corrective surgery for pectus excavatum and cardiovascular disorders simultaneously. Three patients also had disorders of lung, which included spontaneous pneumothorax in 2 patients and progressive emphysematous cyst in 1 patient. The 2 patients with spontaneous pneumothorax underwent resection of bullae together with corrective surgery of pectus excavatum, while the patient with progressive emphysematous cyst underwent resection of bullae in a separate surgery after correction of pectus excavatum. Cardiovascular disorders were aggravated in 6 of the 20 patients who could be follow up. A total of 4 (20%) patients died long after surgery. CONCLUSIONS: We corrected pectus excavatum in 33 patients with Marfan syndrome, and obtained favorable outcomes. The postsurgical outcome depends on progression of lesions of the heart and large vessels, and it is essential to monitor such lesions carefully.

Nitinol stent for the treatment of tracheobronchial stenosis.

OBJECTIVE: The purpose of this study was to evaluate the potential utility of implantation of a nickel-titanium alloy (nitinol) stent for the treatment of malignant or benign tracheobronchial stenosis. METHODS: We evaluated 18 patients (14 men and 4 women) who received 24 nitinol stents, between November 1997 and May 2000. All 18 patients had severe dyspnea caused by tracheobronchial stenosis. The underlying condition was malignant disease in 15 patients, and benign tracheal collapse in the other 3 patients. RESULTS: Implantation of the stent was successfully performed in all patients. Seventeen patients experienced immediate clinical improvement in respiratory symptoms. The remaining 1 patient with a bronchial fistule after lobectomy did not benefit, and died of pneumonia at 16 days after the implantation. In 15 patients, the procedure was performed using a flexible bronchoscope under local anesthesia alone, while the remaining 3 patients needed intravenous sedation. There was no complication resulting from the stent implantation. Among the 3 patients with benign tracheal collapse, 2 patients were alive at 746 and at 401 days after the stent implantation, at the time of this report. One patient with cicatricial stenosis after intubation died of heart failure due to previous myocardial infarction. Among the 15 patients with malignant disease, 4 patients have survived for 177 to 305 days to date, while the other 11 patients have died of primary malignancy with a mean survival duration of 60.2 days. CONCLUSION: The nitinol stent was effective in treating malignant or benign tracheobronchial stenosis, and had some remarkable advantages compared with other tracheobronchial stents. In stenting, most procedures can be performed using flexible bronchoscope under local anesthesia.

Wallstent endovascular prosthesis for the treatment of superior vena cava syndrome.

OBJECTIVE: We assessed the clinical outcome of self-expanding Wallstent endovascular prosthesis in the treatment of superior vena cava syndrome due to malignant tumors. METHODS: Eleven patients with malignant superior vena cava syndrome were treated by percutaneous implantation of the self-expanding Wallstent endovascular prosthesis across the stricture site. Patency was defined by the absence of symptoms and signs of superior vena cava syndrome. RESULTS: Ten of the 11 experienced complete symptomatic relief within 3 days of stent implantation. The remaining 1 did not benefit, and required a second procedure, dying of heart failure 5 days after stent implantation. Ten patients remain symptomatically free of superior vena cava syndrome to date or until death in follow-up lasting 17 to 227 days. CONCLUSION: Implantation of the self-expanding Wallstent endovascular prosthesis for malignant superior vena cava syndrome provides rapid symptomatic relief and improves the patient's quality of life.

Surgical management of multidrug-resistant tuberculosis.

We report surgical resections in 3 patients with active multidrug-resistant tuberculosis. All cases involved strains of Mycobacterium tuberculosis resistant to at least isoniazid and rifampin and patients who were poor candidates for medical therapy alone. We conducted pulmonary resections (partial resection in case 1, lobectomy in case 2, and segmentectomy in case 3). The optimum multiple-drug regimen, based on drug susceptibility studies, was used preoperatively and postoperatively. In all cases, sputum smears and cultures yielded negative results postoperatively, and continue to be negative for Mycobacterium tuberculosis to date. It is recommended that, if localized disease is present and medical treatment is likely to fail, pulmonary resection be conducted for multidrug-resistant Mycobacterium tuberculosis.

Pulmonary multiple metastases of ovarian granulosa cell tumor 15 years after initial diagnosis.

We report a case of multiple pulmonary metastases occurring 15 years after an ovarian granulosa cell tumor was initially diagnosed. A 62-year-old woman undergoing left salpingo-oophorectomy for a granulosa cell tumor of the left ovary 15 years earlier presented with abnormal chest shadows. Computed tomography of the chest confirmed the presence of 3 well-defined nodular lesions, and Computed tomography of the abdomen and pelvis revealed a 3.5 x 2.5 cm partially solid, cystic pelvic mass. Left thoracotomy was conducted and tumors diagnosed a pulmonary metastases of a granulosa cell tumor. The pelvic mass was resected and infracolic omentectomy then conducted with total hysterectomy and right salpingo-oophorectomy including the adherent rectal segment. The pelvic mass proved to be a granulosa cell tumor. Adjuvant combination chemotherapy was started every 3 weeks and the woman has remained disease-free for 9 months.

[One case of chronic pyothorax with MRSA infection cured by air-plombage method].

It is very difficult to cure a chronic pyothorax with MRSA infection. We experienced one such case with low pulmonary function (VC 1700 ml, %VC 50.7%), 73 years old man, who had a history of esophageal cancer and was operated two years ago. As the control of bacteria and the surgical intervention are both important in the treatment of pyothorax cases, we tried to reduce MRSA by washing with Povidone-Iodine solution through the drain. Then, we selected Air-plombage method as it is expected to maintain or to increase the pulmonary function after operation. We could easily close the bronchial fistula with a muscle flap, as it was located at the centre of the cavity. During the operation we frequently used acidic electrolyzed NaCl solution against MRSA. For one month after the operation, we used Vancomycin which is effective against MRSA, however, rather severe side effects were seen, and finally and MRSA vanished. Pulmonary function has improved from the initial VC 1700 ml, %VC 50.7% to VC 2120 ml, %VC 63.6% one year later. We recommend Air-plombage method for such cases with low pulmonary function under the control of MRSA by using acidic solution.

A new host record of Camelostrongylus mentulatus (Nematoda; Trichostrongyloidea) from abomasum of a giraffe at a zoo in Japan.

Camelostrongylus mentulatus (Railliet et Henry, 1909) Orloff, 1933 (Nematoda; Trichostrongyloidea) was found from the abomasum of a three-year-old female cape giraffe, Giraffa camelopardalis giraffa, born and died in a zoo park in Yamaguchi prefecture, Japan. This is the new host record from Giraffidae and geographical distribution of C. mentulatus. Present case of C. mentulatus might be infected from other ruminants, e.g., camels, antelopes and goats, kept at a same paddock in the zoo. Risk of imported parasitic diseases by the zoo animals from outside of Japan is discussed.

[Eight cases of thymic carcinoma].

Eight cases of thymic carcinoma (mean age 62 years, 5 males and 3 females) were treated in our hospital from Apr. 1988 to Mar. 1993, which were 21% of thymic epithelial tumors. The histologic subtypes of thymic carcinoma were 3 squamous, 4 undifferentiated, and 1 adenocarcinoma, respectively. Computed tomography showed extrathymic metastases to the mediastinal lymph nodes in 6 cases. All cases underwent thoracotomy, and postoperative radiotherapy or chemotherapy were performed. A case of squamous cell carcinoma in stage II who underwent total resection followed by irradiation is alive and disease free 5 years after surgery. However, the remaining 7 cases died of the disease within 29 months. 8 cases of thymic carcinoma and 7 of thymoma were studied immunohistologically on the formalin-fixed and paraffin-embedded tissues. Higher positivity of EMA in thymic carcinoma was noted comparing to ordinary thymoma, suggesting that EMA is a useful parameter of potential malignancy of the thymic epithelial neoplasms.

[A case report of primary fibrosarcoma originated in the heart invading adjacent organs ].

A rare case of cardiogenic fibrosarcoma is reported. A 66 y.o. male with dyspnea, cough and fatigue was examined. B-mode echo, MRI, and angiography disclosed a large tumor in the left atrium. A large fibrosarcoma and 2 cm of the left atrial wall around the tumor pedicle were removed. The atrial defect and right lower pulmonary vein were repaired with a patch. Four months later, the tumor recurred in the right lung, mediastinum, and left atrium. The tumor, middle and lower lobes of the right lung, and part of the left atrial wall were excised. One year after the first operation, the patient died of air way obstruction due to another recurrence of the fibrosarcoma in the left lung, esophagus, and mediastinum. Cardiogenic fibrosarcoma invading outward for the mediastinal organs is rare.

[A case of old pulmonary tuberculosis with repeated hemoptysis which presented therapeutic difficulties].

A 74-year-old male who had been infected with pulmonary tuberculosis since 1938 underwent thoracoplasty in 1955. After the operation, no symptoms manifested until 1988 when he developed hemosputum and hemoptysis in association with a cold with fever. Although he was admitted to a hospital, the symptoms could not be controlled, so he was referred to our department. The lesion causing the hemorrhage was considered to be in the upper lobe of the left lung. However, it would have been difficult to preserve respiratory function in the case of left upper lobectomy, because he had already undergone thoracoplasty on the right side. Therefore, bronchial artery embolization (BAE) using Spongel was performed. Second embolization was performed because hemoptysis referred after one month. However, the hemoptysis recurred again, so that two branches of the left subclavian artery and the left internal thoracic artery were ligated. No hemoptysis and hemosputum occurred for a while, but 2 years and 9 months after the operation, the patient was admitted due to hemoptysis with fever and coughing. Since the bronchial artery was embolized twice with spongel and twice with platinum coil, the patient's course has been good for 5 months.

[A case of pulmonary solitary metastasis of renal cell carcinoma nine years after radical nephrectomy].

A 65-year-old woman was admitted to our department when a routine screening chest X-ray film demonstrated pulmonary solitary nodule. Nine years before, left nephrectomy had been performed with a diagnosis of renal cell carcinoma, and postoperative course was uneventful. Chest X-ray and CT confirmed the presence of well-circumscribed mass in the right lower lobe of lung. With a presumptive diagnosis of pulmonary metastasis of renal cell carcinoma, right lower lobectomy and resection of mediastinal lymph nodes was performed. The pathological diagnosis was metastasis of renal cell carcinoma, granular cell subtype. Pulmonary solitary metastasis of renal cell carcinoma, especially nine years after radical nephrectomy is rare case.

[A case of bilateral coronary artery fistulae into main pulmonary artery].

A case of coronary-pulmonary artery fistulae was presented with the review of the literature. A 46-year-old man was admitted to our department with an ischemic change in leads III, a VF on ECG. Although he had no complaint, the exercise ECG showed significant depression of ST segment in leads II, III, V4, V5. Coronary angiography revealed fistulae from left anterior descending branch to main pulmonary artery, and also from right coronary artery to main pulmonary artery. No coronary organic narrowing were found. Ligation of the fistulae was performed and postoperative course was uneventful.

[A case of bronchial anastomotic stenosis after right upper sleeve lobectomy treated with silicone stent].

A case treated with silicone stent for bronchial granulomatous stenosis caused by anastomosis after right upper sleeve lobectomy was reported. A 68-year-old man complained of atelectasis of right upper lobe due to squamous cell carcinoma was admitted to our department. We performed right upper sleeve lobectomy. Four weeks after the operation, hemoptysis and dyspnea appeared with developing local empyema. We performed closure of pleural fistula and thoracoplasty, however, did not improve the symptoms. We performed tracheotomy for deteriorating dyspnea. In addition, granulomatous stenosis of bronchial anastomotic site was observed endoscopically. We tried to insert silicone stent into stenotic site. Although, first trial was in failure, we modified the design of the stent and succeeded in fixation of the stent. The airway was completely re-opened and good patency had been maintained for 7 months until his death due to pneumonia.

[A case report of coronary artery bypass surgery (3-SVG) in 80-year-old woman with acute respiratory failure].

A successful operation for a patient of unstable angina with hypoxia is reported. A 80-year-old woman was admitted with severe chest oppression. The selective coronary angiogram revealed 3-vessel disease. Symptoms were uncontrolled by medical therapy. Aorto-coronary bypass surgery (with 3-saphenous vein grafts) was followed by excellent post-operative course. The patient has been asymptomatic for more than 1 year after operation.

[A two-year-old child with tracheal stenosis due to tracheostomy treated by end-to-end anastomosis of the trachea].

Successful operation performed on a 2-year-old boy with tracheal stenosis due to long-term intubation was reported. He was admitted to our department 1 year after a neurosurgical operation. Endoscopically, destruction of cartilage rings was observed just above the site of tracheostomy, and the tracheal wall was collapsed without a help of tracheal tube. Reconstruction of the trachea by circumferential resection and end-to-end anastomosis was done. During the operation, the patient was uniformly ventilated by tracheal tube through nasal intubation. After the operation, tracheal intubation was continued for 7 days, and anterior fixation of neck for 8 days. The postoperative course was uneventful and the patient remains asymptomatic 8 months after operation.