We report our experience with decreasing in length of postoperative hospital stay and decreasing costs in patients with lung cancer. Between April and September 1997, a total of 48 patients with lung cancer underwent pulmonary resections at our institution : 24 video-assisted lobectomy, 20 lobectomy through an anterolateral thoracotomy, 2 lobectomy through a standard posterolateral thoracotomy, 1 pneumonectomy through an anterolateral thoracotomy, and 1 exploratory thoracotomy without pulmonary resection. Two patients who underwent video-assisted lobectomy and lobectomy through an anterolateral thoracotomy could not leave hospital because of postoperative interstitial pneumonitis and apoplexy, respectively. The remaining 45 patients, except these two and the other one undergoing exploratory thoracotomy, could be discharged uneventfully, and the average length of postoperative hospitalization was gradually shortened from : 16.9 days in April, 14.6 days in May, 13.5 days in June, 9.0 days in July, 7.1 days in August, and 6.6 days in September. This is because from April, we instruct our patients about the necessity of early return to work, and have improved postoperative analgesics without increasing procedure-related costs. We should decrease these costs because of the financial difficulties of the national medical insurance system.

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To predict the behavior of colorectal cancer metastasis to lung, DNA ploidy and S phase fraction (SPF) were analyzed in primary and lung metastatic lesions of 23 patients. The average SPF of primary and lung metastatic lesions were 10.5±5.7% and 9.4±5.5%, respectively in DNA diploid tumors. On the other hand, in DNA aneuploidy tumors, they were 24.0±8.3%and 23.9±8.3%, respectively. There were no significant differences in SPF between primary and lung metastatic lesions. When DNA ploidy patterns between primary and lung metastatic lesions were compared, 4 of 7 (57.1%) showed the same ploidy status in DNA diploid tumors, while in DNA aneuploid tumors all eleven showed DNA aneuploidy. As a result, fifteen cases exhibited consistent DNA ploidy status between primary and lung metastatic lesions and a linear correlation on SPF values was observed in these case. These results showed that the SPF value in primary lesion could predict the SPF value in metastatic lung lesions. In DNA aneuploid tumors, SPF were reciprocally correlated with disease-free interval (DFI) in both primary and metastatic lung lesions. As for prognosis after lung resection, univariate analyses of prognostic factors showed that DNA ploidy patterns and SPF were not prognostic indicators, whereas primary lymphnode involvement, numbers of lung metastases, and intrathoracic lymphnode metastases were significant prognostic factors. In conclusion, SPF is a useful indicator for predicting DFI, though factors related to metastasis may be more prognostic than proliferative activity after lung resection for colorectal cancer metastases.

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Hyperhidrosis of the palms and axillae has a strong negative impact on the patients social and professional life. The existing non-operative therapeutic options seldom give sufficient relief, and its effects are usually transient. Surgical sympathectomies have been performed to treat the palmar hyperhidrosis.
This letter describes the video assisted thoracoscopic technique for bilateral sympathectomy. We also report some technical improvements.
Between August 1995 and September 1997, we performed 17 video assisted thoracoscopic sympathectomies for the treatment of palmar hyperhidrosis. We performed bilateral sympathectomy by removing the T2 and T3 sympathetic ganglions. The patient was placed in the semi-Fowler's position under general anesthesia. Sympathectomies on both sides were performed without changing the patient's position. Immediate and dramatic decrease in the sweat excretion in the palms was noted in all patients. Fifteen patients were highly satisfied with the results. The commonest side effects were compensatory sweating (11/17, 65%). In two patients, this was more embarrassing than the original form of hyperhidrosis. Postoperative Horner's syndrome was not observed. Video assisted thoracoscopic sympathectomy is a minimally invasive procedure for the palmar hyperhidrosis, but enough effective, safe and reliable. This procedure is strongly recommended for the patients they need surgical treatments of upper limb hyperhidrosis.

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To determine whether cryopreserved trachea can be a substitute for tracheal replacement, we performed 3-step experimental study. First, we evaluated the viability of cryopreserved tracheal allografts in immunosuppressant free transplantation in dogs. Second, we investigated the origin of the epithelium in transplanted cryopreserved tracheal allografts in rats. Third, we examined histological changes and bacterial contamination of the human bronchus during the process of cryopreservation.
(1) Cryopreserved tracheal allotransplantation in dogs
Methods : In group A (n= 6), a cryopreserved tracheal allograft, which had been stored in liquid nitrogen (-196°C) after freezing to-80°C by a programmed freezer, in group B (n= 5), a fresh autograft, and in group C (n = 4), a fresh allograft were transplanted by replacing the thoracic segment of the trachea using an omental flap without immunosuppressive agents.
Results : In groups A and B, all dogs survived, but in group C, all died of airway obstruction between 1 to 2 months after the operation. Histologically, the cryopreserved allograft segment displayed normal epithelium and cartilage, but the fresh allograft segment showed chronic inflammatory changes with a lack of epithelium and cartilage.
(2) Epithelial regeneration in transplanted cryopreserved trachea in rats
Methods : Tracheal transplantation was performed (n=6) using PVG rats (allele at RT 1-locus : c) as a donor and ACI rats (allele at RT 1-locus. a) as a recipient. After resection of a five-ring segment of the cervical trachea, the trachea was reconstructed using the cryopreserved tracheal segment of a PVG rat (n = 6). No immunosuppressive agents including steroids were given to them.
Results : At 2 months after tracheal transplantation, 6 surviving ACI rats were killed. Histologically, the epithelium and tracheal cartilage of the transplanted cryopreserved segment displayed a normal structure. Immunohistochemical staining showed that the MHC Class I antigen of the ACI rat was expressed in the epithelium of the transplanted segment and that the MHC Class I antigen of the PVG rat was expressed in the cartilage of the transplanted segment.
(3) Cryopreservation of human bronchus
Methods : Six lobar bronchi were harvested from the resected lung of cancer patients and histological changes and bacterial contamination before and after cryopreservation were examined.
Results : No bacterial growth was detected after 2448 hours storage at 4°C or at thawing of the cryopreserved human bronchi. The epithelium of the human bronchi was almost deleted after cryopreservation.
[Conclusions] The epithelium, smooth muscle and cartilage were retained after implantation of cryopreserved tracheal allografts vascularized with the omentum and without immunosuppression. After transplantation of the cryopreserved trachea, the epithelium of the transplanted cryopreserved segment was originated from the recipient epithelium, while the donor's cartilage retained the structure of the trachea. The epithelium of the human bronchus was almost deleted after the process of cryopreservation. We believe that transplantation of a cryopreserved trachea leads to the growth of the recipient's epithelium over the donor's trachea, thereby reducing the antigenicity of the transplant.

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Ninety-one patients with small cell lung cancer (SCLC) who underwent lung resection were retrospectively reviewed and the surgical indications and necessity of chemotherapy for early stage SCLC were discussed. The actuarial 3-and 5-year survival rates were 40.8% and 34.0 % for all cases, 53.5% and 45.6% for c-stage I, 19.2% and 19.2% for c-stage II, 12.5% and 0% for c-stage IIIA, 55.8% and 47.0% for p-stage I, 50.0% and 50.0% for p-stage II, and 4.5 % and 0% for p-stage IIIA, respectively. In the p-stage I-II patients who underwent complete resection, the 3-and 5-year survival rates were significantly better for patients treated by surgery and chemotherapy (61.4% and 57.0%) than those treated by surgery alone (14.8% and 14.8%). The 3-and 5-year survival rates of the p-stage I-II patients medicated by more than four courses of chemotherapy were both 87.5%. These results suggest that surgery may be indicated for c-stage I and p-stage I-II SCLC patients and that more than four courses of adjuvant chemotherapy is indispensable even in these early stages of SCLC.

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A 4-years-old boy was admitted with stridor. A chest X-ray film showed a mass shadow in the right upper mediastinum. The trachea was oppressed to the left and strictured. We suspected that the mass was an esophageal cyst or a broncheal cyst. The intramural cyst of the esophagus was successfully removed. The size of the cyst was 5 × 5 × 4 cm and 3 mm thick. The pathological examination showed a squamous epithelium and a double muscle layer. Cartilage and a broncheal gland were not seen. We diagnosed the cyst as an esophageal cyst. After the operation the stridor disappeared.
It seems that congenital mediastinal cyst in infants may cause severe airway obstructive symptoms.

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Operation for giant emphysematous bullae was performed by standard thoracotomy for two patients and good results were obtained by devising the resection of bullae. A 36-year-old male with giant bullae in the apex of both lungs underwent bullectomy bilaterally twice.
Another subject was a 39-year-old male who underwent the same procedure for a giant bulla detected in the apex of the right lung.
The following are points of this operation.
(1) Upon opening the air-containing cavity (bulla), loose strands of fibrous tissue are revealed.
(2) We should not search for communicating bronchioles, nor close them directly.
(3) Then through-and-through mattress sutures are placed at the base of the bulla through healthy lung tissue and are tied to plication. The sutures are retracted to outside of the lung and are completely removed with the base of the bulla including the communicating bronchioles by application of stapling instruments.
(4) At the same time the wall of the bulla is put between the jaws of a stapler and is helpful for reinforcement of the stapling line. The residual wall is trimmed.
Postoperative courses were uneventful without any complications.

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A 66-year old woman was admitted presenting with dyspnea and chest pain. She had a past history of artificial pneumothorax for pulmonary tuberculosis 41 years previously. Chest roentgenography showed a huge mass shadow with calcification in the left entire pleural space. Chest computed tomography and magnetic resonance imaging showed that an encapsulated tumor with calcification compressed the esophagus, major vessels, trachea and contralateral side lung. Diagnostic thoracotomy and tumor extirpation with left pneumonectomy was performed. The histological diagnosis was not a malignancy but chronic expanding hematoma. The huge mass contained many hematomas resulted from repeated bleeding caused by respiratory motion and cough over a protracted period. It is very difficult to diagnose chronic expanding hematoma clinically. Surgery alone can improve symptoms and make a diagnosis of the CEH despite of potential complications such as massive bleeding.

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We report a case of schwannoma in the brachial plexus that was resected from the cervical area. A 67-year-old man demonstrated a tumor shadow at the right pulmonary apex on chest X-ray. MRI scan showed that the mass was a neurogenic tumor originating from the right brachial plexus.
We resected this tumor from the cervical area and obtained a good view of the brachial plexus. The spindle tumor below the anterior scalenus muscle, 45 mm in maximum diameter, was connected to the 8^th cervical nerve of the brachial plexus. The tumor was resected by enucleation since it was confirmed to be benign on frozen sections. Immediately following surgery, the patient had a slight ulnar nerve palsy, which completely healed after 6 months.
Regarding the surgical procedure for schwannoma in the brachial plexus, we consider this approach which allows a good view might be useful. It was recently reported that irreversible nerve injuries sometimes occur with the thoracoscopic approach.

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We experienced a case of eosinophilic granuloma (EG) complicated with recurrent pneumothorax, diabetes insipidus and skin lesions.
Asymptomatic pneumothorax was pointed out in a 19-year-old male on chest simple roentogenogram and treated with chest drainage at the first admission. Two months later, pneumothorax recurred and bullectomy was performed. He was re-operated on eighteen months after the first operation for bilateral pneumothoraces and diagnosed as having EG of the lung. Skin lesions resembling acne, and slight polyuria, ignored at the first operation, were also due to this condition based on skin biopsy, brain MRI and hypophysial function tests.
Pathologic signs of EG on chest simple roentogenograms had not been detected in the inflated lung by the time of diagnosis at which the lung was severely destroyed on chest CT. In the literature, smoking cessation seems to be very important for this disease.
For the reasons mentioned above, it is of importance to obtain a chest CT early as well as perform thorough anamnesis and physical examination for prompt diagnosis and medical guidance, even if the diagnosis appears to be spontaneous pneumothorax.

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We treated a 68-year-old man who had both left lung adenocarcinoma and abdominal aortic aneurysm. Main tumor of the left upper lobe formed a mass of 7cm in diameter with metastatic anterior-mediastinal lymph node, and the lung cancer was diagnosed as clinical stage IIIA (T3 N2M0). The infra-renal aortic aneurysm was 6cm in diameter. One stage operation was indicated for both lung and aortic lesions. Through median sternotomy and laparotomy with additional anterolateral thoractomy, left upper lobectomy with lymphadenectomy and aneurysmectomy with interposition of the abdominal aorta were performed simultaneously. The whole chest cavity was visualized well by using a lifting retractor substituted for rib retractor. Unclean manipulations such as transection of the bronchus and lung tissue were done after closing the abdomen. As microscopic invasion was detected in the adventitia of the aorta, the lung cancer was diagnosed as stage IIIB (pT4N3M0). The patient received additional mediastinal radiation therapy.

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A quite rare case of cavernous hemangioma of the lung is reported. A 46-year-old man was referred to our institution for an abnormal shadow on chest roentgenogram. He had no symptoms. Chest X-ray film showed a faint mass with illdefined margin in the right lower lung field. Chest CT scan demonstrated a sharply demarcated homogeneous mass with irregular margin in the S⁸ and S⁹ segments. The patient underwent thoracotomy. An elastic soft mass was found in the right basal segment. A part of the tumor was exposed on the surface of the lung, and that was a crowd of vessels. The resected tumor measured 5.0×5.0×4.0cm, and had no definite capsules. Microscopic examination revealed cavernous hemangiomatous pattern with irregularly dilated blood-filled spaces.

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Debridement and drainage with video-assisted thoracic surgery (VATS) for acute empyema were performed in five patients who had undergone thoracentesis, irrigation and administration of antibiotics preoperatively. Surgery was done 28 days after onset. Treatment utilizing VATS was performed gently to remove fibrin clots and septae from both visceral and parietal pleural surfaces and achieve drainage after irrigation. Mean operative time and intraoperative blood loss were 173 minutes and 304ml, respectively. All cases have had a good postoperative course, with the exception of one case with persistent bacterial discharge, and the mean hospital stay was 32 days after VATS. In conclusion, VATS for acute empyema is effective and should be attempted when lasting inflammation and insufficient re-expansion of lung is shown in fibrinopurulent phase.

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A 60-year-old woman was referred to us for an abnormal mass at the right pulmonary hilum on X-ray film. Computed tomography showed a round homogenous mass 4 cm in diameter located in S^7-8 of the right lung. On magnetic resonance imaging, the intensity of the mass was equal to that of muscle tissues. Under a preoperative diagnosis of a solid tumor, right lower lobectomy was performed. After the operation, macroscopic examination demonstrated that the resected mass was not a solid tumor, but a cyst with a solid content which resembled processed cheese. Histopathological findings revealed that the content was a non-specific necrotic tissue and the cystic wall was comprised of a pseudostratified, ciliated epithelium and a fibrous tissue including smooth muscle. By these findings, the mass was finally diagnosed as a bronchogenic cyst. To our knowledge, a solid content in a bronchogenic cyst is very rare and, so far, has never been reported.

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A 32-year-old woman was admitted with a complaint of left back pain. Her chest X-ray showed a 7.5×5.7 cm tumor shadow in the upper left lung field. Chest CT showed an intrathoracic mass adjacent to the chest wall.
Transcutaneous needle biopsy showed leiomyosarcoma. A wide en bloc excision of the chest wall was performed including the 3rd, 4th and 5th ribs. The chest wall defect was closed with Malex mesh. The histological diagnosis was leiomyosarcoma of the chest wall. The surgical margin was free of the sarcoma. Eight months after the operation, she was found to have a metastatic brain tumor in the left frontal lobe on the routine brain CT scan without any symptoms. The tumor was successfully treated with the stereotactic radiosurgery, resulting in the survival up to 3years and 6months with no evidence of the tumor relapse.

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We report a case of giant mediastinal neurinoma with expansion into the intraspinal canal. We resected the tumor safely with the two-stage operation. The patient was a 52-year-old male. An abnormal shadow in the left lung field was pointed out at a mass survey. The tumor shadow was 15 cm in size, and extended into the intraspinal canal on chest X-ray, CT, and MRI. It was diagnosed as neurinoma by percutaneous fine needle biopsy (PCNB). First we resected the intraspinal portion of the tumor by the posterior route.
Subsequently, the remaining intrathoracic portion of the tumor was resected and reconstruction of the spinal column was performed via the postero-lateral route six weeks later.
Pathological diagnosis was benign neurinoma. The patient improved neurologically, discharged on his foot and had been well after two years.

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A 71-year-old female was admitted to our hospital for further examination of an anterior median chest wall mass with gradual growth and slight pain for 4 years in September 1996. A smooth, elastic hard and unmovable mass was recognized on the upper portion of the sternum. The mass was measured 11×9 cm. Chest MRI showed a tumor of the manubrium invading the body of the sternum and bilateral clavicle. Bone scintillation film showed a strong accumulation in the manubrium. Other various examinations showed no abnormal findings in other organs. Aspiration needle biopsy revealed a primary sternal chondrosarcoma. At operation the sternum was cut just above the adherent portion to the 4th ribs as the upper end, and removed including median half parts of the bilateral clavicle and bilateral median parts of the 1st to 3rd ribs. The line of resection was 3cm beyond the margin of the tumor. The skeletal reconstruction was performed using doubled soft Marlex mesh. Bilateral pectoral major muscles were mobilized and approximated on the soft Marlex mesh.
Postoperatively, the pulmonary function, and mobility of the bilateral upper extremities and neck were not reduced. The patient is alive and well without any sign of recurrence 9 months after the operation.

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