We investigated the effect and mechanism of action of potassium in flushing solution on lung graft function. Five groups of rabbits with different potassium concentration solutions were evaluated : Group 1 (n = 7), 0mEq/L ; Group 2 (n= 6), 5mEq/L ; Group 3 (n= 6), 10mEq/L ; Group 4 (n=6), 15mEq/L and Group 5 (n=10), 20mEq/L. The grafts were topically flushed in vivo with the respective solutions and harvested. After 18 hours preservation at 8°C, graft function assessment was performed. We used the system in our department which utilizes autologous blood. The graft was placed in a closed circuit for 30minutes. We defined this period as the first reperfusion. The circuit was then intercepted, and the grafts were perfused with preserved autologous blood for 120 seconds. We defined this period as the second reperfusion.
During flushing, the mean pulmonary artery pressure (PAP) was significantly higher (p < 0.05-0.01) in Group 5 than in the other groups. During the 1st reperfusion, 2 cases in Group 2 were excluded due to extreme values on Smirnov test. Two cases in Group 4 and 4 cases in Group 5 were excluded due to lung edema. During the 1st reperfusion, a significant indirect correlation was found between average PAP (avPAP) in each group (Y) and potassium concentration (X) (Y = 24.2 +0.85X ; r = 0.912, p <0.01). During the 2nd reperfusion, a significant correlation was found between mean PAP (Y) in each group and potassium concentration (X) at 60 sec and 120 sec.
(60sec : Y=17.674+2.322X ; r=0.917, p<0.01)
(120sec : Y=21.112+2.738X ; r=0.919, p<0.01)
An indirect correlation between mean pO₂ (Y) and potassium concentration (X) was observed at both 60 sec and 120 sec.
(60sec : Y=162.552-3.615X ; r=0.964, p<0.01)
(120sec : Y=147.888-3.708X ; r=0.913, p<0.01)
Based on F-test for avPAP in the 1st reperfusion and PAP at two points during the 2nd reperfusion, the 5 groups could be divided into two groups : A) Group 1-3 and B) Group 4-5. On comparison of Group A with Group B, a significant difference (p < 0.05-0.01) was found in avPAP in the 1st reperfusion and pO₂ and PAP during the 2nd reperfusion. The above results suggest that potassium ion may injure the graft and thereby affect its function.
We presumed that the above findings were related to the action of potassium ion channels, therefor added Ba²⁺ into the solution for Group 1 (Group 1 + Ba²⁺ (n=6)) and Group 5 (Group 5+ Ba²⁺ (n=6)). During flushing, the PAP (mean± SD) in Group 1+ Ba²⁺ (12.5±1.00) was significantly higher (p <0.05-0.01) than in Group 1 (11.2 ±0.86). However, there was no significant difference between the PAP in Group 5 + Ba²⁺ and Group 5 without Ba²⁺. Although there was no significant difference in the results between Group 1+ Ba²⁺ and Group 1 during graft function assessment, the results of average PAP during the 1st reperfusion and pO₂ and PAP during the 2nd reperfusion of Group 5+ Ba ^2v were significantly better than those of Group 5.
We conclude that the potassium concentration in flush solution should be within 10mEq/L, or it may be desirable to have a flush solution without potassium. This special characteristic of lung flush solutions is likely to be related to the potassium ion channel.

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We evaluated 12 patients who underwent tracheal segmental resection. Nine had malignant neoplasm (thyroid carcinoma, 7 ; tracheal adenoid cystic carcinoma, 1 ; esophageal carcinoma, 1) and 3 benign stenoses (traumatic stenosis, 2 ; postradiotherapic stenosis, 1). Seven underwent laryngotracheal anastomosis, and 5 tracheotracheal anastomosis. The number of resected tracheal rings was 3 to 12 (5.8 ± 2.6). Anastomotic leakage occurred in 2 patients in whom more than 7 tracheal rings were removed. One of them previously received high dose radiotherapy (60 Gy), and the other concurrently underwent bilateral neck and mediastinal lymph node dissection as well as combined resection of internal jugular and innominate veins. The average period until the patients could swallow without dysphagia was 24.5 ± 19.3 days after operation. The 3-year and 5-year survival rates of the patients with thyroid carcinoma who underwent tracheal segmental resection were 85.7 % and 57.1 %, respectively. These results suggested that extensive regional lymph node dissection and combined resection of adjacent organs as well as the number of resected tracheal rings and previous radiation might be the risk factors of anastomotic leakage. Tracheal segmental resection should be performed as curative resection for the patients with thyroid carcinoma invading the airway.

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We studied the influence of the concentration of HES on pulmonary edema during preservation and after reperfusion. The lungs of 25 mongrel dogs were isolated and flushed with 500 ml of one four different solutions at 4°C ventilating with room air. The lungs of each group were flushed and cold-stored as follows : group 1 with modified-Collins (CM) solution (n=6); group 2, CM + 3 % HES (n = 6); group 3, CM + 6 % HES (n = 8); group 4, CM + 9 % HES (n 5). After cold-storage for 24 hours, the isolated left lung was reperfused for 120 min. The left lung was ventilated with room air at a tidal volume of 20 ml/kg of body weight and a rate of 10 cycles/min. The flow rate was maintained at 10 ml/kg/min. The extravascular lung water was calculated and tissue protein present in the lungs was measured, and the histological findings of the lung specimen were examined before and after reperfusion.
The extravascular lung water after reperfusion for 2 hours ; group 1, 88.9 ± 2.1 % ; group 2, 86.6 ± 2.3 % ; group 3, 84.6 ± 1.7 %, ; group 4, 85.6 ± 2. 4 % ; the values in groups 3 and 4 were significantly lower than that in group 1. Tissue protein after perfusion for 2 hours in groups 3 and 4 was significantly lower than that in groups 1 and 2. Pulmonary edema after perfusion was more minimal in group 4 than in the other groups, suggesting that hyperoncotic solution prevents pulmonary edema during both preservation and reperfusion periods.

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Although video-assisted thoracoscopic surgery (VATS) is widely used in the treatment of spontaneous pneumothorax as a less painful surgical approach, some patients complain of severe pain after VATS. The purpose of this study is to evaluate the efficacy of intercostal nerve block (ICB) with bupivacaine in VATS to decrease postoperative pain. We reviewed 80 patients who underwent VATS treatment of pneumothorax in our institution : 40 with ICB in VATS (group A) and remaining 40 without ICB (group B). No procedure-related complications on ICB occurred in group A. Chest tubes were removed on postoperative day 1 in all patients. Analgesic requirements were significantly decreased in group A than in group B not only on the operative day but also on the other postoperative days (group A, 0.6 times/day ; group B, 1.0 times/day, p =0.0018). Length of postoperative hospitalization was significantly shorter in the group A (group A, 3.3 days ; group B, 4.7 days, p = 0.0025). Our results indicate that ICB in VATS could relieve postoperative pain and allow earlier discharge. We conclude that ICB is useful and safe for control of postoperative pain in VATS.

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We performed thoracoscopic surgery for benign localized mesothelioma of the pleura. The patient, a 53-year-old male, was admitted with an abnormal shadow on chest X-ray. Chest CT showed a localized tumor on the right chest wall, and we suspected a neurogenic tumor or mesothelioma of the pleura in the differential diagnosis. Under thoracoscopy the tumor which was connected to the pleura was completely resected with combined partial resection of the pleura. Pathological diagnosis was a benign fibrous mesothelioma. The post operative course was uneventful.
We conclude that thoracoscopic surgery is well indicated and the treatment of choice for a benign localized mesothelioma.

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We report a case in which we successfully diagnosed and treated a minute lung carcinoma using video-assisted thoracic surgery (VATS). A 49-year-old man was admitted to our hospital for further examination of a minute pulmonary lesion (8 × 8 mm) on a CT scan obtained at a periodic checkup. VATS biopsy of the pulmonary nodule was carried out. Frozen section examination of this nodule confirmed the diagnosis of adenocarcinoma followed by VATS lobectomy with mediastinal lymph node dissection was performed. VATS biopsy can be considered as an initial diagnostic procedure for minute peripheral pulmonary lesions.

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A 63-year-old man was being followed by his home doctor under the diagnosis of chronic empyema complicated with pulmonary tuberculosis. He complained of dyspnea. After admission to our hospital, increasing of right empyema cavity was recognized on chest X-ray and chest CT scan. Modified air-plombage (extrapleural air-plombage) was performed. After this operation, PaO₂ has been remarkably improved for 12 months. We consider that extrapleural air-plombage can preserve intercostal muscles, and therefore neither extreme shrinkage nor deformity of hemithorax has been observed after surgery, compared with standard air-plombage (extraperiosteal air-plombage). Additionally, extrapleural air-plombage is a simple and safe surgical procedure, so this method can be employed to total thoracic empyema, which is a contra-indication to extraperiosteal air-plombage.

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A 23-year-old female had been pointed out a mediastinal abnormal shadow on chest X-ray film during antithyroid medication for Basedow's disease. She was referred to our hospital for recurrence of hyperthyroidism and increased size of the mediastinal shadow. Chest CT and MRI showed a diffusely enlarged thymus, which was suggestive of thymic hyperplasia. Median sternotomy and total thymectomy were performed on August 6, 1997. The thymus weighed 85 g, and the right lobe was 12.5×5.0 cm in size, and the left lobe 13.5×6.3 cm. Histological examination revealed lymphoid hyperplasia. Her postoperative course was uneventful, and she has been taking medicine for Basedow's disease.

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A 33-year-old female was admitted with cough and chest pain. The chest CT scan showed a 10cm cyst of anterior mediastinum. The level of CA19-9 was 12531U/ml in the serum and more than 2.4 ×10⁶U/ml in the cystic fluid. Operative findings revealed that the cyst was intrapericardial and was removed completely. The pathological diagnosis was bronchogenic cyst lined by ciliated epithelium and contained bronchial glands, cartilage, smooth muscle and alveolar structures. Postoperative course was uneventful arid the level of CA19-9 decreased to normal.

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A 74-year-old woman was admitted to our hospital because of a giant mediastinal mass shadow at the right pulmonary hilum on chest X-ray films. A chest CT scan showed a mediastinal cystic mass with rim calcification. Thoracotomy and cystectomy was performed under the diagnosis of a bronchogenic cyst. Partial resection of SVC was necessary because of tight adhesion to the mass. Pathologic examination revealed a large cyst without epithelial cells on the inner surface and with calcification and inflammatory change in the cyst wall. Rim calcification was considered to be due to chronic inflammation, and careful treatment is necessary at the operation of calcified mediastinal cyst.

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A 69-year-old male who had undergone right upper lobectomy and mediastinal lymph node dissection for advanced lung cancer developed interstitial pneumonia on the third postoperative day. Pulse steroid therapy was performed immediately. The patient was successfully recovered.
During the eleven years from June 1984 to December 1995, a retrospective review identified 9 patients with postoperative interstitial pneumonia (PIP). They had all undergone operation for advanced lung cancer on the right side, and interstitial shadows appeared in the left lower lung field on the opposite side. Seven of these patients had undergone complete dissection to the right upper mediastinal lymph node. We conclude that detection of an initial vague shadow in the lower lung field on the non-operated side should be the sign for immediate initiation of pulse steroid therapy for treatment of PIP, especially in patients with advanced lung cancer on the right side accompanied by complete lymph node dissection of the mediastinum.

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We present two cases of intraoperative intrathoracic hypotonic chemotherapy (HCT) consisting of distilled water and anticancer platinum complex for stage IVa thymoma. One case was a 59-year-old woman showing right recurrent pleural dissemination with pure red cell aplasia 42months after initial operation for the stage IVa thymoma with myasthenia gravis. She underwent resection for the dissemination and intraoperative HCT. The another case was a 42-year-old man having a thymoma with left carcinomatous pleuritis. He received resection for the main tumor and dissemination as completely as possible with HCT following 4 courses of combination chemotherapy. Both cases have shown radiographically no retention of pleural effusion for 16 months and 6 months, respectively, after operation. HCT seems effective for control of pleuritis carcinomatosa caused by thymoma.

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A 41-year-old woman was injured in a farm cart accident. Because of the chest roentgenogram obtained in the emergency department showing left hemothorax, a chest tube was inserted. However respiratory sound was not audible on the left lung field. Chest CT scan demonstrated complete obstruction of the left main bronchus. Bronchofiberscopy revealed complete obstruction of the left main bronchus. Emergency thoracotomy was performed, five hours after the accident. Complete transection of the left main bronchus and laceration of the left main bronchial membrane to the carina were found. End-to-end anastomosis with interrupted 3-0 PDS sutures was performed. Postoperatively her clinical course was uneventful.

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We report a case of non-Hodgkin malignant lymphoma developed in pyothoracic wall following artificial pneumothorax.
A 79-year-old man, who had underwent an artificial pneumothorax for pulmonary tuberculosis 42 years ago, was admitted to our hospital for a painful mass of the left chest wall.
The chest radiograph revealed a diffuse opacity of the left lung with pleural thickness. Chest CT showed a thickened and calcified pyothoracic wall, and a tumor which invaded the chest wall and ribs.
The enbloc resection of tumor and chest wall resection including the 8th, 9th, and 10th ribs was performed.
Histological diagnosis of the resected specimen was non-Hodgkin's malignant lymphoma, diffuse, large, B-cell type.
In Japan, about 100 cases of non-Hodgkin's lymphoma with chronic tuberculous pyothorax have been reported, although few cases were resected. The patient is well with no evidence of the recurrence for 2 years after the operation.

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In patients with T4 bronchogenic carcinoma, preoperative evaluation of mediastinal invasion by the tumor is important in the determination of not only staging but also technical resectability. This case report describes the application of intravascular ultrasound (IVUS) imaging for the patient with the findings of aorta invasion by the tumor on either CT or MRI. IVUS imaging could provide definitive information that the tumor did not invade the adventitia of the aorta. That shows the clinical value of IVUS so as not to overstage the disease, thereby precluding potentially curative surgery.

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