Two preservation methods, non-flush surface cooling (SC) and pulmonary flush with low potassium dextran glucose (LPDG) solution, were compared in a canine bilateral single lung transplantation (BSLT) model. The former method was used in the first successful human lung transplantation and the latter method had been proved to preserve lungs safely for 24 hours in a canine left lung transplantation model. Donor lungs were assigned randomly to one of the following two groups, SC proup (n=6) and LPDG group (n=5), and preserved for 5-6 hrs. BSLT was performed without cardiopulmonary bypass. Recipient animals were kept on a ventilator for 12 hrs after transplantation for serial assessment. All animals in both groups survived for the 12-hour observation period with excellent lung function. PaO₂ (FiO₂=1.0), PaCO₂ and mean pulmonary artery pressure were 482 ± 67, 37.6 ±4.6, 20.1±3.4 Torr, respec-tively, in the SC group and 590 ± 18, 44.3 ± 4.0, 27.3 ± 3. 0 Torr, respectively, in the LPDG group. No significant difference in lung function was observed between the two groups. These results lead us to conclude that both non-flush surface cooling and pulmonary flush with LPDG solution are useful methods for lung preservation up to 5-6 hrs in a canine BSLT model.

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The incidence of bronchopleural fistula after stapling and suturing in 832 pulmonary resec-tions was reveiwed. There were 8 fistulas in 332 stapled cases (lobectomy, 3 ; bilobectomy, 3 ; pneumonectomy, 1.). We found that leg length 3.5 mm staples were sometimes too tight to close a lobar bronchus. Use of the proper size of staple is extremely important to avoid the complication of bronchopleural fistula. The stapler should not to be used when the bronchus is inflamed or thickened. There were 6 fistulas in 500 sutured cases (lobectomy, 2 ; bilobectomy, 2 ; pneumonectomy, 2), 5 of them in 294 sutured with Sweet's method and only 1 in 206 sutured with Overholt's. We think that the latter method is best for bronchus closure if the surgeon is skillful enough to perform good suturing.

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Indications for pulomonary resection are currently being studied with emphasis on the postoperative quality of life. If the postoperative exercise capacity can be quantified by an objective method, the changes can be studied in detail, and it will be very useful for the predction of the degree of postoperative recovery. This objective method should also be an effective index of the rehabilitation of patients following pulmonary resection. In the present study, the authors attempted to determine whether expired gas analysis together with exercise testing can predict accurately exercise capacity in daily life following pulmonary resection.
The subjects were 22 patients who underwent curative surgery for lung cancer between November 1989 and October 1991 and who were examined with exercise tests and expired gas analysis after it had been confirmed by postoperative clinical examinations that they had no relapse. The measurements were performed 27 to 99 days postoperatively (average, 53.4±18.8 days). Energy Measurement System 2900 was used for the expired gas analysis, and a bicycle ergometer was used for the exercise test. The load was started at 30 Watts and increased by 10 Watts every 2 minutes up to 60 Watts, then by 20 Watts every 2 minutes. A Borg rating of more than 17 of the perceived exertion scale was used as a landmark for the load. The expired gas analysis was performed every 20 seconds, the anaerobic threshold (AT) and maximum oxygen consumption (VO₂max) were determined, and AT/m² and VO₂max/m² were calculated as indices by dividing the above values by the body surface area to minimize errors due to individual differences. AT was calculated by the V-slope method, and the maximum value was taken as VO₂ max. Prior to the postoperative measurements, all subjects were interviewed, and they were divided into group A and group B. Patients with no change or only a slight reduction in exercise capacity but no difficulty with daily activities after surgery were placed in group A, while those with definite reduction in exercise capacity and any difficulty with daily activities were placed in group B. The measured data were compared in the two groups. The postoperative interviews concentrated on items related to exercise capacity and any difficulties with daily activities. Group A included 12 patients, eight males and four females with a median age of 61.3±8.4 years, and in group B there were 15 patients, 10 males and five females with a median age of 67.0±8.1 years. Statistical analysis was performed with Studen's t test : a difference of p < 0.05 was considered significant. All values were expressed as mean±standard deviation.
AT was 539 100 ml/min in group A and 405±79 ml/min in group B-a significant difference (p<0.001). AT/m² was 358±29 ml/min/m² in group A and 277±52 ml/min/m² in group B-also a significant difference (p<0.001). The p-values were the same for AT and AT/m², but AT/m² showed a smaller standard deviation. VO₂max was 883±242 ml/min in group A and 651±125 ml/min in Group B-a significant difference (p<0.01). VO₂max was 586±145 ml/ min/m² in group A and 446±77 ml/min/m² in group B-also a significant difference (p<0.01).The p-values were the same for VO₂ max and VO₂ max/m², but the standard deviation for VO₂ max/m², was smaller.
Exercise tests and expired gas analysis were performed as objective indices to quantify exercise capacity following pulmonary resection. AT/m² appeared to be a useful index in comparatively early postoperative evaluations.

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In a series of 1460 patients who underwent lung resection in Shimada Municipal Hospital and the Chest Disease Research Institute of Kyoto University from September 1980 to December 1992, contralateral pneumothorax developed in four. The mean age was 56 years. Preoperative chest x-ray film and chest CT revealed bilateral bullae in three of the four patients. Contralateral pneumothorax occurred intraoperatively in one, within 7 days after lung resection in two and 47 months after operation in one. Except in the intraoperative case, dyspnea and chest pain were the chief complaints. The final diagnosis was confirmed by chest x-ray film revealing contralateral pneumothorax. Immediately after diagnosis the patients underwent chest drainage. Air leakage was stopped within 3 days in three, and they recovered well. Because of continuous air leakage, we performed ligation of the base of a ruptured bulla under thoracoscopy in one patient, and the results were good. Contralateral pneumothorax is a rare complication after lung resection, but a delay in the diagnosis may lead to chronic problems or death. Chest drainage is effective as emergency treatment. In patients with continuous air leakage, surgical treatment is necessary. Thoracoscopic treatment is an option for contralater-al pneumothorax after lung resection.

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Sixty surgical patients and 137 non-surgical patients with T4 lung cancer were studied in respect of diagnosis, outcome of patients and prognostic factors. Among 60 patients with T4 lung cancer diagnosed pathologically (pT4), clinical T4 (cT4) lung cancer had been recognized preoperatively in only 16 (26.7%). The 19 surgical pratients with cT4 lung cancer resulted postoperatively in pT4 in 16 (84.2%). Accurate diagnoses and underestimations of N factors were made in 26 of the pT4 cases (43.3%) respectively. The 5-year survival rate was 13.9%, compared with 8% for 137 non-surgical cT4 cases. The 3-year surviors had low levels of N and M factors, invasion of a single organ and adjuvant therapy. No correlation between pre/ post-surgical factors and prognosis was found except in cN3 and surgical curability.
Surgery is possibly indicated in cases of cT4, cNO-2, cMO-1 including pulmonary metastasis.

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Thoracoscopic surgery and thoracotomy as surgical treatments for spontaneous pneumothorax were compared and discussed from the view point of operative intervention and monitoring of CK and CRP values. The subjects were 36 patients with spontaneous pneumothorax treated surgically from January to the end of December 1992. Thoracotomy was performed in 29 and thoracoscopic surgery in 7, one of whom had 2 thoracoscopic procedures. There was no significant difference between the 2 groups as to age, length of hospitalization, period following surgery, time from onset to surgery, length of time drainage tube was used following surgery, or operation time. Postoperative creatine kinase (CK) (mUK/ml) levels and CRP levels were compared. CK was significantly lower one day after surgery and CRP one and three days after surgery, in the thoracoscopic surgery group. Thus demonstrates the superiority of thoracoscopic surgery over thoracotomy.

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A routine chest x-ray film of a 54-year-old man showed an abnormal shadow in the right cardiophrenic angle. Computed tomography and magnetic resonance imaging revealed a pericardial cyst. The cyst was resected in a thoracoscopic procedure. Under the left hemi-lateral position, 4 Surgi ports were inserted through the 4th, 5th and 6th intercostal spaces in the anterior axillary line and 5th intercostal space in the mid-clavicular line. The pericardial cyst was punctured, and its content was confirmed to be serous fluid. The cyst was dissected from its upper side with scissors, and all bleeding points were electrocauterized. There were no fenestrations between the cyst and the pericardial space. The operation time was 120 minutes. The patient was discharged on the 14th postoperative day. Thoracoscopic resection is less invasive and causes less blood loss, and the hospital stay is shorter.

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We treated 50 patients with spontaneous pneumothorax by thoracoscopic surgery, 33 of them recieved treatment for bullas and blebs, pleurectomy and chemical pleurodesis. These are considered to be the three principal techniques for spontaneous pnemothorax under videothoracoscopy. The complications of this treatment in 50 patients were intraoperative bleeding in 2 patients (11.8 %) and mechanical lung injury in one (5.9 %). The period of extubation of the chest drain for the 33 patients was 5 days ± 1 days. The follow-up period ranged from 1 to 29 months. During this period, recurrence was not seen in any of 33 patients with spontaneous pneumothorax. We conclude that video-thoracoscopic surgery is effective and safe in the treatment of spontaneous pneumothorax.

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A 45-year-old woman underwent anterior spinal fusion of the upper lumbar vertebrae (Th12 -L3) for burst fracture of the first lumbar vertebra in Kyoto University Hospital on August 21, 1992. The early postoperative course was uneventful, but left pleural effusion increased starting 2 weeks after operation. She visited our outpatient clinic on September 20. White milky effusion was aspirated by thoracentesis, and a diagnosis of chylothorax was made. She underwent intravenous hyperalimentation and chest drainage for 4 weeks, but the chylothorax persisted. Surgery was performed on Octorber 30, 1982. The top of the anterior spinal fusion device was seen beside the 11th thoracic vertebra, and serous effusion ran down along the device. This was wrapped by the diaphragm with 20 interrupted sutures of 3-0 Vicryl with figrin glue. Chylothorax recurred when oral feeding started, so IVH was resumed for 3 weeks, and pleurodesis was performed twice. Chylothorax after spinal surgery is rare. This report describes the successful surgical treatment of a patient with chylothorax after anterior spinal fusion.

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The patient was a 53-year-old woman whose chest X-ray showed a round mass with a cavity in the left S⁶. We performed bronchoscopy three times but the correct diagnosis could not be obtained. The mass continued to grow and a new lesion appeared in the left S10. Malignancy was not ruled out, so left lower lobectomy was performed. Histopathologically, the specimens showed necrotizing granuloma and vasculitis of unknown origin. The pathological diagnosis was Wegener's granulomatosis. Two months after operation, multiple mass lesions appeared in both lungs. We administered cyclophosphamide, 100 mg a day, and the lesions disappeared. She is well without any evidence of recurrence two years after surgery.

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A 67-year-old female with squamous cell carcinoma of the left lung received an intrapericardial pneumonectomy. Only part of the pericardium was repaired, and a defect of 3 × 2 cm remained. Recovery was satisfactory until 48 hours after surgery, when cardiac herniation occurred suddenly with hypotension, tachycardia and cyanosis. A chest X-ray revealed protrusion of the heart into the left thorax. Chest computer tomography confirmed cardiac herniation. Rethoracotomy was performed, and the heart was returned to its normal position, and pericardial defect was repaired with a Lyodura patch. The patient recovered.
Computer tomography is very useful in the diagnosis of cardiac herniation, as are chest x-rays. To prevent cardiac herniation, pericardial defects should be fully repaired with strong material if direct suture closure is not possible.

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A 67-year-old women was found to have a well-demarcated, round shadow, 8mm in diameter, in the left lower lobe on her chest X-ray. A definitive diagnosis could not be made by bronchoscopy. With a preoperative diagnosis of benign lung tumor, she underwent resection of the tumor. The histological appearance of the tumor was consistent with hemangiopericytoma with no findings suggestive of malignancy. She was followed for 19 months after surgery, when a metastatic nodule was found in the left hilum. Tumorectomy was again performed, and no recurrence has been observed for 14 months after reoperation. Although there were no malignant features in either the primary or the metastatic tumor in the histological exmination, the DNA ploidy pattern and proliferating cell nuclear antigen expression suggested the possibility of predicting the malignant potential of these tumors.

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We treated three patients with posterior mediasinal or chest wall tumors : paraganglioma, intramuscular hemangioma, intramuscular lipoma. The tumors were resected through a paravertebral extrapleural approach by a modification of Yoneyama's method.
Through this approach, all three tumors were resected safely without any postoperative complications. This approach is better and more useful than a postrero-lateral approach for tumors originating in the paravertebral resion for the following reasons : direct visualization of the tumor, less time consuming, no harm to lungs, better postoperative movement of upper extremities, more cosmetically desirable.
We recommend this approach in the treatment of patients with benign posterior mediastinal or posterior chest wall tumors.

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The patient is a 62-year old man. He had active pulmonary tuberculosis since August of 1988. Because of the resistence of his bacilli against most of the potent anti-tuberculosis drugs and continual discharges of bacilli in his sputa, he was referred to our hospital for surgical treatment. Right upper lobectomy was carried out on Aug. 21, 1990 followed by thoracoplasty on Oct. 9. Unfortunately, minor bronchial fistula and MRSA empyema supervened. Since there was no improvement of the empyera with daily intrathoracic lavage, fenestrasion of the empyema space with removal of the upper 3 ribs was done on Dec. 20. With daily cleansing, the bottom of the open wound could be made shallower with some of the raw surface area of the S⁶ segment remaining exposed. On Apr. 16 of 1991, an attempt was made to cover this fenestration wound surface with a scapular flap measuring 14 × 8cm. With the exception of minor abscesses noted on several occasions necessitating minor drainage procedures and finally ending up as a tiny cutaneous fistula, the scapular flap successfully coverd the entire wound, including the exposed surface of the S⁶ segment.

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A 55-year-old man was admitted because his chest X-ray showed an abnormal shadow in the right hilar region. Transbronchial lung biopsy specimens examined immunohistochemically showed infiltration by T and B lymphocytes and plasma cells, and cytological tests of specimens obtained by transbronchial aspiration revealed small cell lung cancer.
Because of tumor invasion of the mediantinum, surgery was performed after chemotherapy. Right pneumonectomy was performed because the right upper bronchus was involved in the tumor. The pathological examination showed malignant lymphoma. No metastatic lesions were found in the mediastinal and hilar lymphnodes.
He died of interstitial pneumonia during a course of postoperative chemotherapy. No evidence of recurrence or metastasis of lymphoma was found at autopsy.
We conclude that the malignant lymphoma originated in the lung.

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A huge localized mesothelioma of the pleura with 5 years history was reported. A seventy-two years old female admitted for evaluation of an abnormal shadow on chest x-ray film. Plain chest x-ray film showed mediastinal shift to the right with a decrease in radiolucency of left lung field. A chest CT revealed a huge tumor occupying all most of the left thoracic cavity. The left lung was oppressed by the tumor, but the tumor margin was sharp and had no direct invasion.
Transcutaneous biopsy suspected a mesothelioma. Tumor shadow (5cm in diameter) of the left lower lung field had been found in the plain film 5 years previously.
We diagnosed that the tumor of the left lower lung field was a localized mesothelioma and grew for 5 years. The tumor was removed surgically.
It weighed 2040g. Histological examination showed it to be a mesothelioma with border-line malignancy.
Some localized mesothelioma exhibit as malignant tumor. Therefore, surgical resection should be done, when mesothelioma is suspected.

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A percutaneous cardiopulmoary support system (PCPS) was used in a 65-year-old man undergoing resect on of a contralateral pulmonary metastasis after a pneumonectomy had been performed for lung cancer. PCPS was utilized immediately after opening of the chest to finish the resection, and a flow of 2.0L/min was achieved. The oxygen saturation of arterial blood from an oximeter set up on the right upper limbs was maintained over 96% in spite of the lack of lung ventilation in the middle of resection. Hemodynamics during the operation were stable, and there were no postoperative complications.
PCPS appears to be a useful method, not only in the treatment of pulmonary resection after pneumonectomy, but also for chest surgery as whole.

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