The relationship between postoperative diaphragm function and changes in transdiaphragmatic central venous pressure during respiration was studied.
Mongrel dogs were anesthetized and allowed to breath spontaneously. Laparotomy by upper abdominal median incision was performed. The superior vena cava pressure (P_SVC), inferior vena cava pressure (P_IVC), esophageal pressure (P_es), and gastric pressure (P_ga) were measured and pressure changes during respiration (ΔP) were recorded. Changes in the transdiaphragmatic gastrointestinal pressure (ΔP_di = ΔP_ga-ΔP_es) and transdiaphragmatic central venous pressure (ΔP'_di = ΔP_IVC-ΔP_SVC) were calculated, as well as the ratios of ΔP_ga/ΔP_di and ΔP_IVC/ΔP'_di.The pressures were measured before and 24 hrs after laparotomy.
ΔP_di and ΔP'_di decreased significantly after laparotomy. There was a significant correlationbetween %Δ (ΔP_di) and %Δ (ΔP'_di). There were no significant changes in ΔP_ga/ΔP_di and ΔP_IVC/ΔP'_di after laparotomy.
Correlations were noted between changes in transdiaphragmatic gastrointestinal pressure durning respiration, which are said to indicate postoperative diaphragm function, and those in transdiaphragmatic central venous pressure. The results suggest that measurement of trans-diaphragmatic central venous pressure can be employed as a parameter for continuous monitoring of postoperative diaphragm function.

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Twenty-nine patients with metastatic lung tumors underwent resection by bilateral thoracotomy. Eleven of them in the early stage underwent staged bilateral thoracotomy and recovered from respiratory insufficiency after a long hospitalization, but died from the disease within 35 months. Eighteen patients in the later stage underwent simultaneous bilateral thoracotomy, and 7 of them underwent lobectomy. However, these 18 patients were free of severe complication irrespective of extensveness of resection ; 10 of them are still alive 5 to 73 months after surgery. These results were no worse than those in patients undergoing unilateral thoracotomy for metastatic lung tumor during the same period. Median sternotomy has the merit of providing quick exposure and closure to minimize operating time and first recovery of pulmonary function. However, there may be a minimal residual lesion if the tumor is located in the posterior aspect of lung. On the other hand, bilateral thoracotomy may result in severe respiratory dysfunction and pain due to extensive destruction of thoracic cage. In the present study, however, these problems were overcome with the use of epidural anesthesia for pain relief.

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To perform low blood flow extracorporeal CO₂ removal (ECCO₂R), we developed a device for extracorporeal circulation (ECC) equipped with a dialyzer for elimination of CO₂ as bicarbonate. The major problem with this method was the decrease in blood pH. To control blood pH and clarify the limit of CO₂ elimination in this method, a study of apneic dogs was performed. Six anesthetized mongrel dogs were intubated and paralyzed with muscle relaxant. Vascular access was achieved with venovenous bypass. ECC was initiated under apneic oxygenation (100% O₂, 10 cm H₂O continuous airway pressure), and the CO₂ concentration in the airway outlet was measured.
The CO₂ was converted to bicarbonate by systemic infusion of trihydroxymethylamino methane (THAM), and generated bicarbonate was removed by hemodialysis. Blood flow rate in the ECC wan 15 ml/kg/min, and the duration of ECC was 5 hr. During ECC, the hemodynamic parameters of the dogs were stable, and the PaCO₂ remained at about 90 mmHg with a PaO₂ above 350 mmHg ; CO₂ elimination from the airway was negligible.

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We performed latissimus dorsi muscle-sparing thoracotomy for patients with primary lung cancer and evaluated its usefulness.
Fifty-three primary lung cancer patients undergoing thoracotomy from September 1988 to July 1989 were randomized into 2 groups : a latissimus dorsi muscle-sparing thoracotomy group (sparing group : n= 23 + 8 consecutive cases) and a standard postero-lateral thoracotomy group (dissecting proup : n=22).
With the use of 2 retractors, reasonably good exposure for lymph node dissection of the upper mediastinum was obtained in the sparing group.
Postoperative differences in pulmonary function could not be found between the two groups ; postoperative analgesic use was less (but not significantly so) in the sparing group. Subcutaneous fluid collection (seroma) after removal of the subcutaneous drains developed in 4 patients (12.9%) in the sparing group, but it was easily treated by repeated bedside needle aspirations.
We concluded that latissimus dorsi muscle-sparing thoracotomy has some advantages in less postoperative pain and better cosmetic results. but there were also some disadvantages in it, so we are not going to adopt muscle-sparing thoracotomy as the standard method for primary lung cancer patients.

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In a series of patients receiving lobectomies for lung cancer, we compared predictions of postoperative respiratory function values in those with restrictive lung disease (n=13) and those without (control group, n=41). Respiratory function was tested before and after surgery : FVC, FEV_1.0, TLC, FRC, RV, DLco. The lung perfusion scanning test was also performed before operation. Postoperative values were predicted by Ali's formula.
The correlation between the predicted and measured postoperative respiratory function values was very close in either group, but between two the groups there were no parallel rows for FVC, FEV_1.0, TLC, FRC, RV or DLco in the analysis of covariance. Slopes of regression lines for FVC, FEV_1.0, TLC in the restrictive group were steeper than those in the control group. For FRC, RV and DLco the slopes in the restrictive group were less steep than those in the control group. We conclude that it is difficult to predict postoperative respiratory function in patients with restrictive lung disease.

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Flexible bronchoscopy was performed in a total of 10 children in our emergency and intensive care unit, 8 of them under 2 years of age. The indications for bronchoscopy were signs of upper airway obstruction, postoperative atelectasis or airway bleeding, pneumonia, and suspicion of foreign bodies. Bronchoscopy was useful in the diagnosis of congenital upper airway anomalies (3 patients) and of bronchial foreign bodies (2 patients), in the detection of bleeding sites and causes of atelectasis. Bronchoscopy was used therapeutically for bronchial toilet (7 cases), as a guide for nasotracheal intubation (4 cases), for bronchial lavage (2 cases) and for dilatation of tracheal stenosis. Pediatric bronchoscopy was performed safely under general anesthesia with tracheal intubation and monitoring with ECG and pulse oximeter. In conclusion, bronchoscopy is useful in emergency and intensive care of children as well as of adults.

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During the past 29 years 104 patients with thymoma were treated in our institute, 49 males, and 55 females. There were 40 patients with stage 1 disease, 13 with stage 2 disease, and 28 with stage 3 disease. Twenty six thymomas were of the epithelial cell type, 30 of the lymphocytic cell type, and 48 of the mixed type.
Patients with stage 1 thymomas had a very good survival rate, while none of those with advanced disease survived for 10 years, but 38% of the patients with stage 3 or 4 disease survived more than 5 years. Therefore patients with stage 3 or 4 disease should be followed at least 10 years.

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A successful two-stage operation (open-window thoracostomy, then omental plombage) for MRSA empyema with bronchopleural fistula is described.
A 56-year-old man underwent tube drainage for empyema following MRSA pneumonia. An open-window thoracostomy was performed because of a persistent air leak and the continued presence of MRSA. Six months later, when MRSA was not found in the sputum or exudate from the wound, omental plombage was performed with a pedicled flap supplied by the left gastroepiploic vessels. Good results were achieved by the second operation.
In this report, we emphasize the importance of decreasing infection by closed or open drainage in the treatment of MRSA empyema.

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We treated three patients with pulmonary dirofilariasis found in resected lungs. Abnormal shadows were noted on routine chest X-rays. Since lung cancer was suspected, pulmonary resections were performed. The histological diagnosis was pulmonary dirofilariasis.
Chest X-ray findings were as follows : 1) plain chest films showed faint shadows with relatively ill-defined margins, 2) laminograms showed dense, uniform, circular shadows with clearly defined margins, 3) CT scans showed elliptical shadows just under the pleura, with a segmental or subsegmental pulmonary artery directed straight toward the mass ; the elliptical shadow showed the so-called “parallel sign”, with its long axis in the same direction as the course of the pulmonary artery.
Although these characteristic findings were noted, we cannot say definitely that they are enough to differentiate dirofilariasis from lung cancer.
An immunological test for Dirofilaria immitis antibodies is needed. In patients with tumorlike shadow on chest X-ray films, it is important to keep in mind the possibility of dirofilariasis.

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A case of intralobar pulmonary sequestration (Pryce type I) is reported here, and the 18 cases reported to date in the Japanese literature are reviewed.
A 31-year-old man who had an abnormal chest X-ray shadow in the left lower lung field was admitted for further examinations. Since CT scans showed an enhanced shadow between the descending aorta and the heart, and the pulmonary angiogram revealed no blood supply to the left basal segments, and the aortogram demonstated an anomalous artery originating from the thoracic aorta and flowing into the left lower lobe, this case was diagnosed as pulmonary sequestration (Pryce tyep I). At thoracotomy, the anomalous artery, 18 mm in diameter, as found to originate from the descending aorta. The vessel was cut and sutured, and left lower lobectomy was performed. The postoperative course was uneventful. Microscopically, the anomalous artery showed atherosclerosis and the pulmonary arteries in the peripheral area of the basal segments revealed obstruction and recanalization.
We collected reports of 18 cases of Pryce type I pulmonary sequestration in Japan. Our patient had the largest anomalous artery. In all one case, pneumonectomy or lobectomy or segmentectomy was performed. In a 13-month-old infant, anastomosis between the anomalous artery and the pulmonary artery was performed. Since our patient was 31 years old and his anomalous artery had atherosclerosis and obstructive changes, left lower lobectomy was thought to be the proper treatment.

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A 53-year-old male had undergone a left upperlobectomy for lung cancer 20 years earlier. Two years ago, left completion pneumonectomy was performed because of refractory atypical mycobacterial infection. Recent chest X-ray film revealed a coin lesion in the right lower lobe. The lesion was resected, the pathological diagnosis was bronchiolo-alveolar cell carcinoma, same as the primary lesion. Pulmonary edema occurred postoperatively, but it improved by mechanical ventilation. The patient is doing well three years after the operation. We consider that a limited operation can be performed even post-pneumonectomy. Surgical resection will improve the prognosis.

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A 31-year-old woman with polymyositis was admitted to our hospital complaining of chest oppression and mild dyspnea. Chest X-rays showed a large smooth mass shadow behind the heart. In the chest CT scan and MR imaging, a homogeneous low density mass surrounded the esophagus and the descending aorta and reached the posterior mediastinum and the retroperitoneum, passing behind the inferior vena cava and the heart. Only a partial resection was performed through a right thoracotomy because the esophagus was completely surrounded by the tumor, which had a tendency to bleed, and she had been taking steroids for a long time. The postoperative course was uneventful, and she has been free of symptoms until the present time, 5 months after surgery. The pathological diagnosis was cavernous lymphangioma. Sixty-five cases of mediastinal lymphangioma have been reported in the Japanese literature.

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There are very few reports of the use of initial chemotherapy prior to surgery or radiotherapy for invasive thymoma. Three patients with bulky invasive thymoma received initial cisplatin-based chemotherapy. In Case 1 with a diagnosis of round-oval epithelial thymoma involving mediastinal great vessels, initial chemotherapy with CDDP, CPA, and VCR was given along with radiation, and complete remission was obtained. In Case 2, mixed epithelial thymoma invading the intrapericardial cavity with pericardial effusion and pleural effusion, initial chemotherapy with CDDP, and VP-16 was given. A partial remission was obtained, but liver dysfunction occurred. Radiotherapy was given preoperatively during liver dysfunction. Tumor extirpation was carried out with resection of the pericardium, left innonimate vein, and part of the left lung. The resected specimen showed diffuse fibrotic changes. Radiotherapy was given postoperatively. In Case 3, spindle epithelial thymoma involving the superior vena cava, initial chemotherapy with CDDP, and VP-16 was given, but no striking reduction in the size of the tumor was noted. The tumor was resected with the pericardium, superior vena cava, and part of the right lung. The superior vena cava was reconstructed with ringed EPTFE grafts. The resected specimen showed partial fibrotic changes. Radiotherapy was given postoperatively.
Initial chemotherapy now be considered prior to surgery or radiotherapy in patients presenting with bulky thymomas.

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Simultaneous bilateral spontaneous pneumothorax occurred in a 19-year old male. The patient was in severe respiratory distress on admission. Chest X-ray demonstrated marked bilateral pneumothorax. Chest tubes were inserted bilaterally, and bilateral axillary thoracotomy was carried out for excision of apical bullae. He recovered uneventfully. In cases of bilateral pneumothorax, delay in diagnosis and treatment could be fatal.
Early diagnosis and aggressive treatment with tube insertion, subsequent bilateral thoracotomy, and resection of bullae, are recommended.

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A 55-year-old man underwent right lower lobectomy in July, 1990 for squamous cell carcinoma. The postoperative diagnosis was pT1N0M0, Stage I. About one and a half years later he had bloody sputum. Bronchoscopy showed a tumor from the orifice of the right upper bronchus to the lower trachea. The histological diagnosis was squamous cell carcinoma. In March, 1991, he had completion right sleeve pneumonectomy. First, via a median sternotomy the right pulmonary artery was sectioned. Second, via left lateral thoracotomy a bronchial anastomosis was performed, followed by excision of the remaining lung. The trachea was resected 3 rings proximal to the carina, and the. left main bronchus was recected at the level of the carina. An anastomosis was then performed with interrupted sutures and was wrapped with thymus fat tissue. The post opearative course was uneventful, and the patient was discharged 50 days after operation.
Completion sleeve pneumonectomy is rare by performed, and the intrapericardial approach to the right main pulmonary artery via median sternotomy is useful in preventing pulmonary artery injury.

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