Pneumonectomy was performed at our facility 104 times from April 1978 to March 1992. Postoperative bronchopleural fistulas occurred in 11 (10.6%) patients, significantly more often (p = 0.017) on the right side than on the left, but there was no correlation with the disease type. Bronchopleural fistula occurred within the first postoperative week in 5 patients and within the first postoperative month in all 11 patients. Four patients (36.4%) died and 7 patients were managed successfully. An omental pedicle was effective and successful in all 5 patients in whom it was used (omentoplasty). In patients without infection, satisfactory results were obtained by single-stage resuture of the fistula and omentoplasty. Infected patients were managed succssfully after sterilization of the empyema cavity by open theracotomy followed by omentoplasty without thoracoplasty. When infection could not be controlled, omentoplasty combined with thoracoplasty and myoplasty were successful. Patients with bronchopleural fistula following pneumonectomy died without exception when treatment failed, suggesting that it is necessary to perform extensive surgery with the use of an omental pedicle.

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We evaluated the usefulness of povidone-iodine sugar ointment (PSO) in the prophylaxis and the treatment of wound infections in patients with empyema treated with open thoracotomy. In 11 patients, whose open thoracotomy wounds were treated with PSO, bacterial growth inhibition in the wounds was achieved for 47.6% out of the days using PSO, While in 5 patients, in whom PSO was not used, bacterial growth inhibition in the wounds was maintained only for 5.8 % out of the days of open thoracotomy. There was significant difference between the two groups (p <0.05). There were no fatal complications in this series.
We suggest that PSO in clinically useful in the prophylaxis and treatment of wound infec-tions after open thoracotomy in patients with empyema.

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Thirteen patients with silicosis underwent thoracotomy for lung cancer at our hospital between 1981 and 1991. All patients were male, and the age range was 6075 (average 65.0± 5.4) years. The average Brinkman index was 707 ± 343. Preoperative pulmonary function test showed severe obstructive disorder ; vital capacity was 3.05±0.44 L, and the 1 sec forced expiratory curve was 61.8±13.2%. The mean tumor diameter size was 2.4±1.7 cm. Nine tumors were located in the hilum and 4 tumors were peripheral. One pneumonectomy and 12 lobectomies were performed. Histological study showed 12 squamous cell carcinomas and one large cell carcinoma. A few mediastinal lymph node metastases detected pathologically. Post-operative complications were frequent. The 5-year survival rate was 42%. These results show that the characteristics of lung cancer with silicosis are clinically and pathologically similar to those of bronchogenic carcinomas induced by aspirated carcinogens. In conclusion, modified radical procedures should be used in these high risk patients because of rare mediastinal lymph node metastases.

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Diaphragm dysfunction in one of the postoperative complications after thracotomy and upperlaparotomy.
The measurement of transdiaphragmatic pressure by the esophago-gastric balloon technique is a method of evaluating diaphragm function, but its use in continuous measurements in postoperative patients is difficult. On the other hand, a central venous catheter has been inserted in most postoperative patients. Provided that transdiaphragmatic pressure can be deduced from transdiaphragmatic central venous pressure, it can be used as a diaphragm function monitor in postoperative patients.
Our animal experiments showed correlations between respiratory changes in transdiaphragmatic gastrointestinal pressure and transdiaphragmatic central venous pressure. In the pressent study, we measured transdiaphragmatic central venous pressure in clinical cases and evaluated its usefulness in determining diaphragm function.
In patients undergoing standerd lobectomy, the superior vena cava mean pressure (P_SVC) and inferior vena cava mean pressure (P_IVC) were measured and pressure changes during respiration (ΔP) were recorded. Changes in the transdiaphragmatic central venous pressure (ΔP_DI =ΔP_IVC-ΔP_SVC) and the ratio of ΔP_IVC/ΔP_DI were calculated. The pressures were measuredbefore, 24 hrs and 48 hrs after thoracotomy, at rest and during maximum forced respiration.
There were no significant changes in ΔP_DI either at rest or during maximum forced respiration. ΔP_IVC/ΔP_DI decreased significantly 24 hrs and 48 hrs after thoracotomy either at rest or during maximum forced respiration.
The results suggest that the measurement of transdiaphragmatic central venous pressure can be employed clinically as a parameter for continuous monitoring of postoperative diaphragm function.

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In 46 patients who underwent surgery at our facility between 1976 and 1991 the histological diagnosis was small cell carcinoma of the lung. The results of treatment were assessed retrospectively. The clinical stage was I in 19 Patients, II in 7, III in 15 and IV in 5. Preoperative chemotherapy was given to 17 patients and postoperative chemotherapy in 23. The 5-year survival rate was 29%, and the median survival time (MST) was 87 weeks in those who had lung resection. The 5-year survival rates was 39%, 40% and 29% for pathological stages I, II and III, respectively. The 5-year survival rate was 30% in the preoperative chemotherapy group and 32% in the postoperative chemothrapy group. In the preoperative chemotherapy group, the 5-year survival rate was as high as 80% for clinical stage I and II, but it was only 38% in the postoperative chemotheray group. The clinical stage and the pathological stage showed a high inconsitency rate of 45.7%, reflecting the presence of advanced stages in many patients. It was considered that preoperative chemotherapy is useful in the surgical treatment of small cell carcinoma of the lung, regardless of its stage.

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Sclerosing hemangioma of the lung was investigated immunohistochemically and clinicopathologically in 10 patients. Nine patients were women, and 8 of the 10 were in the fourth to sixth decades. All the patients were asymptomatic, and most of the lesions were discovered during routine screening. The lesions appeared as solitary round shadows in chest X-ray films, and prevalent lesion was middle lobe and left lower lobe. Chest X-ray tomography and chest CT were helpful to differentiate from cancer and fine needle aspiration cytology was useful for the diagnosis. The average tumor doubling time of four patients was 1254 days. This suggests that the tumor has slow growing nature. This disease clinically appears to be a benign lung tumor. In all the patients histopathological examination revealed proliferation of pale cells ; these occupied most of the tumor in half of the patients. Immunohistochemical studies showed some epithelial membrane antigen (EMA) was seen in the cell membrane of the pale cells in 9 patients and surfactant apoprotein (PE-10) was present slightly in the cytoplasm of the pale cells in only 3 patients. These findings only suggest that pale cells are derived from epithelial cells, and it is hard to say specifically that the origin is type II pneumocytes. Further case study is necessary to specify that pale cells are type II pneumocytes origin.

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Three patients without symptoms had abnormal shadows on routine chest roentogenograms. Other two had some respiratory symptoms. In four patients, a nodular lesion was seen in the chest film, while one patient had marked eosinophilia and a pyramidal shadow which changed to a mass-like shadow after one week. All patients underwent diagnostic thoracotomy. Histopathological examination showed necrotic granulomatous lesions surrounded by fibrous tissue, and in the embolized pulmonary artery, a transverse section of Dirofilaria immitis was found. Non-invasive diagnostic tests are preferred, since this disease requires no particular treatment. Serological screening for pulmonary dirofilariasis was useful. In all five patients, enzyme-linked immunosorbent assays showed high antibody titers to Dirofilaria immitis.

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A 60-year-old man complained of cough and swelling and pain of both arms. Chest radiography and CT scans showed atelectasis in the left upper lobe caused by a tumor. Transbronchial lung biopsy was performed, and a histological diagnosis of adenocarcinoma was established. Bone radiography showed subperiosteal new bone formation in the upper extremities. Bone scintigraphy, performed with 99m-Tc-MDP, showed abnormal accumulations in the tubular bones of both arms and patellas, and in the left leg. For months after left upper lobectomy, the clinical, radiological and scintigraphic abnormal findings disappeared. The differential diagnosis pulmonary hypertrophic osteoarthropathy is important. In addition to clinical signs, bone scintigraphy is helpful diagnostically.

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A bronchogenic cyst in the middle mediastinum was removed by thoracoscopic surgery. The patient was a 42 year old female whose routine chest roentgenogram showed a huge mass in the middle mediastinum. A CT scan showed a low-density, cystic and lobulated lesion in the chest. MRI revealed that the mass had high signal intensity on both T1-and T2-weighted images. Thoracoscopic surgery was performed under general anesthesia with unilateral ventilation. The thoracoscope was inserted through the 6th intercostal space in the posterior axillary line. The contents of the cystic mass were aspirated. Cytological examination showed no cancer cells. The parietal pleura was divided by a hook, coagulation was performed with electric cautery, and the mass was freed from the mediastinal tissue and pulled out through the chest wall at the 4th intercostal space. The histological diagnosis was bronchogenic cyst. The chest tube was removed on the 2nd post operative day, and the patient was discharged 7 days after surgery.

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A 29 year-old man had a very large malignant germ cell tumor, a terato carcinoma producing alphafetoprotein (AFP) and human chorionic gonadotropin (HCG). After radiotherapy, this giant tumor was completely removed with combined resection of the right lung, pleura, pericardium and right brachiocephalic vein. A local recurrence was treated with chemotherapy and insertion of an expandable metalic stent into the stenotic trachea compressed by the tumor.
He died of respiratory insufficiency nine months after surgery. An autopsy showed the local giant tumor with infiltrative rupture into the trachea. Mediastinal malignant germ cell tumors progress rapidly, so it is important to diagnose these tumors and start the treatment as early as possible.

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A 17-year-old male was involved in a motorcycle accident on June 6, 1989. Three days later, he developed a cough after swallowing.
An esophagogram confirmed tracheoesophageal fistula. He underwent primary treatment (gastrostomy, etc.) and was referred to us for radical operation on postinjury day 63.
A right postero-lateral thoracotomy was performed through the fourth intercostal space. The fistula (35 mm × 8 mm) was located just above the carina between the membranous portion of the trachea and the anterior wall of the esophagus. The fistula was divided, the trachea was closed with a single layer of interrupted 4-0 PDS, and the esophagus was closed in two layers with interrupted 3-0 vicryl sutures. A pedicled 4th intercostal muscle was interposed between the tracheal and esophageal suture lines to prevent recanalization.
The postoperative course was uneventful.

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A 59-year-old man with chondrosarcoma of the sternum received replacement of the completely resected sternum with a prosthesis, which consisted of methyl methacrylic mesin and alumina ceramic pins. The implant was slightly larger than the defect of the chest wall and was fixed to the ribs with 5 alumina ceramic pins, 2 on the left and 3 on the right. This implant was stable for 3 years, but it dislocated into the left chest cavity when he lifted heavy furniture, and 2 of the ceramic pins injured the left upper lobe of the lung, causing hemoptysis. Retection of the pins and partial resection of the injured lung were performed. The dislocated implant was well fixed with connective tissue to the surroundings. Th patient returned to his job in good condition. The unsuitable size of the implant and insufficient fixation of the implant to the sternum were thought to be the main causes of this event.

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A 61-year-old male was admitted for further examination of an anterior mediastinal mass noted on routine chest X-rays. With a presumptive diagnosis of thymoma, total thymectomy with dissection of regional lymph nodes was performed. The cut surface of the tumor in the thymus, 12 × 8 × 7 cm in size, was spongy with marked hemorrhage and scattered solid foci. Microscopically, the tumor cells in the solid foci formed a trabecular pattern, and in the spongy area, islands of the tumor cells with mitotic figures were surrounded by massive interstitial hemorrhage. The tumor cells were stained with the Grimelius silver impregnation technique. The diagnosis was carcinoid tumor of the thymus. We discuss the mechanism of intratumoral hemorrhage on the basis of the histopathological findings.

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A 21-year-old asymptomatic man was admitted to the hospital with an abnormal shadow on chest X-ray films, which was suspected to be a mediastinal mass. CT scan, MRI and endoscopic ultrasonography showed a cystic tumor in the right superior mediastinum adjoining the right wall of the trachea. A bronchogenic cyst was suspected, and anteroaxillary thoracotomy was performed on November 12, 1991. The cyst was located in the superior mediastinum, above the azygos vein, posterior to the superior vena cava and connected to the thoracic duct. It was easily removed by blunt and sharp dissection after ligation and division of the thoracic duct. The cyst was 55 × 35 × 30 mm in size, had a thin wall and some trabecular structures in the lumen, and contained translucent yellow fiuid. Microscopically, Sudan III stain revealed fluid with numerous macrophages containing fat droplets. His postoperative course was uneventful, and he was discharged from the hospital on the sixth postoperative day.

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A 28-year-old male was admitted for further examination of an abnormal shadow in his chest roentgenogram, which had increased in size during the past year. His chest roentgenogram revealed a mass shadow in the left lower lung field. CT scan showed that it extended from the pericardium to the chest wall. Trweighted Magnetic Resonance Images showed it to be located above the diaphragm. A preoperative diagnosis was intrathoracic tumor, probably pleural mesothelioma. At surgery the tumor was found to be pedunculated and originaing from the visceral pleura adjacent to the pericardium. The pathological diagnosis of the resected specimen was benign localized mesothelioma.

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We report a case of small cell endocrine lung carcinoma with metastasis to the palatine tonsil 9 months after resection of lung cancer. A 52-year-old man was admitted to our department with sudden bleeding from the throat. A tumor was noted in the right palatine tonsil the surface of which was swollen and uneven and covered partially with white crust. Biopsy was done, and the pathological diagnosis was metastatic tonsillar tumor from lung carcinoma. The right palatine tonsil and submandibular lymph gland were removed, and neck lymphnode dissection was performed. One of the cervical lymphnodes contained metastatic cancer tissue, but there was no evidence of direct invasion from it to the palatine tonsil. There have been only 18 cases reports of metastatic tonsillar tumors from lung cancer in the Japanese and English literature. There are some reasons for this : (1) lymphatic spread is hard to explain because of the lack of afferent lymphatics to the tonsils ; (2) the tonsils strong immune function protects it better than can other organs from invasion by tumor. The histological type was small cell carcinoma in 13 cases, large cell carcinoma in 3 cases, adenocarcinoma in 1 case and unknown type in 1 case. Our patient had the characteristic features of small cell neuroendocrine carcinoma. Unfortunately he died 9 months after tonsillectomy.

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In this paper we described a 52-year-old female patient with bronchopleural-cutaneous fistula with an open cavity. She had been diagnosed as having aspergilloma of the right lung and had had a cavernotomy and thoracoplasty at another hospital in 1988. Since then a bronchopleuralcutaneous fistula with an open cavity appeared in the surgical scar. She consulted us in July 1991. We performed right pneumonectomy and repeat-thoracoplasty, which resulted in postpneumonectomy empyema with bronchopleural fistula. We tried repeatedly to close the fistula with fibrin sealant through endoscopy, but the technique did not succeed. Therefore, we performed an omentopexy theree months after our first operation. The patient made an uneventful recovery. We consider omentopexy to be effective for postpneumonectomy bronchopleural fistula.

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