Lung cancers were curatively resected in 191 patients with pathological stage I disease in our department from 1971 to 1990. Fourteen patients (7.3%) had their initial recurrence within 2 years (early recurrence group). Ten of the 14 had the initial recurrence in a distant organ, two at the same site, and two at both local and distant sites. The postoperative 2-year survival rate of the 14 was 57.1%, and the 5-year survival rate was only 7.1%. On the other hand, 52 (27.2%) of the 191 patients had no evidence of recurrence for five years (5-year-disease-free group). We analyzed the characteristics of the early recurrence group and compared them with those of the 5-year-disease-free group to identify significant variables influencing postoperative early recurrence. It was found that the mean diameter of the primary tumor in the early recurrence group was significantly greater than that in the 5-year-disease-free group (4.6 ± 2. 2cm vs 3.1 ± 1.4cm, p = 0.01 by Student's t-test). And the mean serum CEA concentration of the former was significantly higher than that of the latter (2.9 ±2.4ng/ml vs 1.3 ±0.7ng/ml, p = 0.04 by Mann-Whitney's U-test).

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During the past 18 years six patients with primary pulmonary cryptococcosis were treated surgically, 3 males and 3 females with an average age of 40.9 years. Four patients were asymptomatic and abnormal shadows were found on routine chest x-ray. One of the 2 symptomatic patients had meningitis. Five patients had solitary tumor-like shadows on chest x-ray and one had multiple nodular shadows. The lesions were located in the right upper lobe in 3, right middle lobe in one, right lower lobe in one and left lower lobe in one. In 5 patients the diagnosis was made by transbronchial or transcutaneous lung biopsy. The reasons for operation were poor response to antifungal drugs or difficulty of continuing drugs due to side effects in 3, meningitis in one, increase of shadow size in one and suspicion of lung cancer in one. The operative procedures were lobectomy in 2, segmentectomy in one and partial resection in 3. There were no serious postoperative complications.
One of the 6 patients died from cardiac failure one year and 6 months after operation. Five patients are alive and well from 2 to 17 years after lung resection. There was no postoperative meningitis or recurrent pulmonary cryptococcosis.

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Between December 1985 and January 1992, a total number of 264 patients with lung cancer were operated on at our insitution, and 32 of them (51 to 70 years of age) were investigated for ischemic heart disease. The reasons for investigation were anginal pain in 8, signs of old myocardial infarction on ECG in 8, ischemic change on ECG in 6, and old age in 11, The investigative procedure included Treadmill tests on 12 patients, T I scintigraphy on 10, and both Treatmill test and T I scintigraphy on 6. Coronary angiography was performed on 15 patients, and significant stenosis was found in 9 of them. On one of these 9 patients, both cardiac and pulmonary surgery were performed simultaneously. In another case P T CA was performed prior to the pulmonary surgery, and in other 2 cases IABP was necessary during the pulmonary surgery. In 5 patients pulmonary surgery was done along with medical therapy for coronary disease. Although in patients with mild to moderate coronary disease pulmonary surgery may be done safely with careful cardiac medication, antecedent coronary revascularization or simultaneous cardiac and pulmonary surgery with lymphnode dissection must be considered in cases with severe coronary disease.

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Bioabsorbable rib-connecting pins made from polylactic acid (PLA pins) were clinically applied to thoracotomy. At the time of chest closure, PLA pins were used to connect the rib cut to enlarge the operating field.
There were 36 subjects including 26 cases of primary lung cancer, 2 cases of metastatic lung cancer, 2 cases of benign pulmonary tumor, and 6 cases of other diseases. The operative procedures consisted of 29 lobectomies, 2 total pneumonectomies, 2 partial pneumonectomies, 2 enucleations, and one segmentectomy.
The PLA pin was evaluated as follows. Its usability at operation was very good in 78% and good in 22% of cases, fixation was good in 94% and poor in 6% and deviation of the pin was seen in 6% but not in 94%. Chest X-ray films detected no lucent zone at the rib-connecting site, healing was good in 100% of cases, and there were no side effects. The overall assessment was useful in 83%, and useful in 6% of cases.
Thus, the PLA pin proved useful for rib reconstruction at thoracotomy. It could also be applied to rib fractures occurring at thoracotomy or due to chest trauma.

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Partial resection of the lung was performed under thoracoscopic guidane using ENDO-GIA to treat spontaneous pneumothorax. In six patients aged from 19 to 32 years old, blebs had been found in the lung apex in preoperative examinations. The mean operation time was 70 minutes. ENDO-GIA was used on an average of five occasions. Pain was only slight after surgery. Surgical drains were removed on the fourth postoperative day, and the patients were dischar-ged from the hospital five days later. The size of the resected blebs ranged from 2 to 6cm (mean : 3.5cm). The size of the resected tissues ranged from 5.5 to 10.5cm (mean : 7.7cm). ENDO-GIA could be manipulated easily during surgery. The procedure proved to be curative in all six patients. We conclude that the procedure is effective in almost all young patients with spontaneous pneumothorax.

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Thoracoscopic partial lobectomy aided by intraoperative ultrasonography was performed in three patients with lung tumors. The diagnosis was probable lung cancer in two and metastasis from a renal pelvic tumor in one. The location of the tumor was determined by intraoperative ultrasonography which allowed us to remove 1-2 cm of tissue surrounding each tumor.
The use of intraoperative ultrasonography in thoracoscopic partial lobectomy for lung tumor is valuable in the location of tumors and in decision of the amount to resect. It extends the indications for thoracoscopic surgery to lung tumors which are normally not resectable by thoracoscopy since intraoperative visual examination of the pleura surface dose not reveal them.

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Preservation of the lung in cold water is difficult because of its buoyancy. We have devised an entirely new method of preservation of the canine lung. The heart-lung graft was initially flushed to lower the temperature to about 13°C. The graft was then suspended in an adiabatic cage, and the lung was inflated by high frequency jet ventilation with normothermic room air. Cooling of the graft was then induced by cold environmental air from outside of the graft. Preservation was performed for six hours at a graft temperature of 6°C. The preserved left lung was transplanted orthotopically. No immunosuppressant was given after transplantation. The function of the transplanted graft was evaluated twice, immediately after transplantation and on the third postoperative day, with inflation of a cuff for the native right pulmonary artery occlusion. Four out of seven animals tolerated this examination well. There were no significant pathological findings. The experiment clarified the usefulness of this method of preservation that fulfilled the essential requirements of lung storage for transplantation.

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A 54-year-old woman was hospitalized for further examination of an abnormal shadow on her chest X-ray. She was asymptomatic, and her laboratory data were normal. Thoracic CT scan revealed a heterogeneous mass shadow enhanced in the central region. Transbronchial brushing cytological examination showed slight nuclear atypisms ; the diagnosis was welldifferentiated adenocarcinoma, class V. She underwent right lower lobectomy and dissection of regional lymph nodes on May 14, 1990. The tumor, located just beneath the pleura, measured 28 × 24mm. Microscopic examination showed the biphasic pattern of a spindle cell mesenchyme and a glandular structure, with massive necrosis and hemorrhage. Tumor cells contained much glycogen and many argyrophilic granules, resembling fetal lung. The pathological diagnosis was pulmonary blastoma, T1NOMO. She has been free of malignancy for 3 years since the operation. The preoperative diagnosis of pulmonary blastoma is discussed.

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A 50-year-old female presented with back pain. A chest X-ray film and MRI films revealed an anterior mediastinal tumor that was smaller than that seen on chest X-ray film and CT-scans taken at another hospital. The patient was operated on via median sternotomy. A tumor was found originating from the right lobe of the thymus. Thymothymectomy was performed. Pathologically, the resected tumor was diagnosed as a lymphocyte-predominant non-invasive thymoma, but most of the tumor cells were necrotic. Spontaneous regression of malignant disease has been reported occasionally, but only four cases of receding thymoma have been reported in the Japanese literature.

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We treated a 15-year-old famale with primary pulmonary hypertension while she was still asymptomatic. After 6 years she died of respiratory failure. Her pulronary hemodynamics monitered by cardiac catheterization showed good response to medical therapy without any symptoms for the first 3 years, but then deterionated, and she suffered repeated hemoptysis, syncope, and heart failure during her last 3 years. The possible effectiveness of lung transplantation for this patient is disccussed retrospectively.

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A 65-year-old man who had bilateral giant emphysematous bullae and left pneumothorax with severe dyspnea (Hugh-Jones V) underwent bullectomy and plication bilaterally twice. Since December, 1986, he had had a productive cough and difficulty in breathing. By February, 1991, he could not stand up by himself because of severe dyspnea, and he was referred to Kosei Hospital for surgery. His condition became critical with severe hypercapnia and hypoxemia (PaCO₂ 54.8Torr, PaO₂ 43.4Torr). His preoperative chest X-ray film showed giant bullae occupying over 50 % of both lungs and left pneumothorax. Two operations were performed. Fibrin glue and staplers were used much for bullectomy along with plication because of the weakness of the remaining emphysematous lungs. After surgery arterial blood gas levels improved (PaCO₂ 47.2Torr, PaO₂ 84Torr), as did pulmonary function (especially FEV_1.0). Now he is no longer dyspneic and can walk by himself.
Resection of bullae may improve the respiratory status of patients with giant bullae and severe respiratory failure if preoperative evaluation is thorough and the operative procedures are appropriate for each patient.

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A 19-year-old female was admitted for treatment of a pneumothorax. Soon after her admission, she developed varicella. After recovery from the varicella infection, a thoracoscopic operation was performed, and a bleb was removed. Histologic examination showed a wall of the bleb with coagulation necrosis and diffuse infiltration with branched hyphae consistent with Aspergillus species. Reduction of host resistance by varicella infection might have led to the deeply infiltrating process in the wall of the bleb. It is also possible that Aspergillosis of a bleb had induced the pneumothorax.

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An 81-year-old male was admitted to our hospital because of an abnormal shadow on chest roentgenogram. Chest roentgenogram and CT revealed a peripheral type lung tumor in the left S¹⁺² without lymph node swelling. Squamous cell carcinoma was demonstrated by bronchoscopic biopsy. Lung function tests showed obstructive respiratory disturbance. His condition was complicated by arrhythmia and diabetes mellitus.
The patient underwent wedge resection by thoracoscopic surgery. His postoperative pain was insignificant. His postoperative course was uneventful. Wedge resection by thoracoscopic surgery is useful for resection of a peripheral type lung cancer without lymph node metastasis.

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A 62-year-old woman with arteriovenous fistulas of the left lung diagnosed 14 years earlier developed brain abscess and was admitted for evaluation and treatment. After surgery for the brain abscess, transcatheter embolization of the pulmonary arteriovenous fistulas was carried out.

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The patient was a 55-year-old female who visited a local physician because of cough and dyspnea on exertion. A chest radiograph revealed an abnormal shadow, and the patient was referred to our hospital for further evaluation. Diagnostic imaging disclosed an anterior mediastinal tumor. A needle biopsy was performed, and a diagnosis of fibrous mesothelioma was made. A routine chest radiograph taken 2 years earlier revealed a 3-cm tumor in the right upper mediastinum. On April 22, 1992, thoracotomy was performed via median sternotomy. The tumor was located in the right anterior mediastinum. Adhesions between the tumor and the right mediastinal pleura, as well as the pericardium, were noted. The tumor was excised with adhesiotomy from the mediastinal pleura and the pericardium. The tumor weighed 545 grams and measured 12.8 × 10.0 × 7.3 cm. A defect in the tumor capsule was present at the site of the tumor's adhesion to the pericardium. A peduncle was seen near the right brachiocephalic vein. Tumor recurrence was detected at the original site 3 months after surgery, and the patient underwent reoperation on July 15. The tumor had already invaded the pericardial cavity. and 4 free tumor nodules were found at the site. The pericardium was partially resected with the tumor. The recurrent tumor weighed 160 grams and measured 9.0 ×7.0 × 5.0cm. Three months after the second operation, the patient died of cardiac tamponade. The recurrent tumor formed a mass within the pericardium.

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A 63-year-old male patient was referred to our hospital due to two masses in the right lung on chest X-ray film, one of which was located in the middle lobe and the other in the lower lobe.
Transbronchial lung biopsy was negative for malignancy.
Microscopically, the specimens obtained by bilobectomy of the right middle and lower lobe showed proliferation of xanthoma cells and lymphocytes, and the histological diagnosis was multiple pulmonary xanthogranuloma originating separately in the middle and lower lobe.
Though xanthogranuloma is classified as an inflammatory pseudotumor, its pathogenesis remains to be fully elucidated.
As it is often difficult to differentiate is from lung cancer, exploratory thoracotomy and resection should be considered for definitive diagnosis.

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Adiaspiromycosis is a rare zoonosis, caused by the fungus Chrysospolium parvum spp. (or Emmonsia crescens), which usually lives in the soil. Despite its ubiquitous occurence in rodents and small wild mammals throughout the world, the disease rarely affects the human lung, and has never invaded the open negative cavity. Therefore, the present case seems to be the first reported one in the world. The patient was a 60-year-old male with a past history of pulmonary tuberculosis, accompanied by severe adhesion of the right pleura and such complications as diabetes mellitus and hypertension. The chest X-ray film and the CT scan revealed an open negative cavity with a fungus ball at the right apex of the lung, which was compatible with pulmonary aspergilloma, so that the lesion was believed to be aspergillosis, which was clarified as adiaspiromycosis after the culture of the extirpated fungus.
“Thoracic wall plombage”, a kind of cavernoplasty with minimal thoracoplasty was carried out for this patient to save bleeding and to prevent operative morbidity and mortality.
The patient has been doing well for two years and a half after the operation, so the combined space reducing procedure for abnormal air space of the lung, such as open negative cavity and bronchogenic cyst seems to be a good alternative to pulmonary resection.

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In Japan there are few reports of gun shot injuries because the owning of guns is not permitted. Recently we treated successfully a 38-year-old man who was shot with a 22-caliber pistol. The bullet penetrated the right lungs from the anterior chest wall to the postero-lateral wall. He underwent emergency open thoracotomy because of a persistent shock state due to massive intrathoracic bleeding. Since there was no injury of the great vessels, the lacerated lung was sutured directly. The postoperative course was uneventful.

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A 49-year-old male with complaints of left chest pain and dyspnea was admitted to our hospital. His X-rays and CT scan showed a right emphysematous giant bulla and multiple left emphysematous bullae. The right thoracic cavity was occupied almost entirely by the giant bulla. Intracavitary suction with a balloon catheter was applied to the right giant bulla to expand the compressed right lung. Intracavitary suction was continued for three weeks until the right middle and lower lobes were reexpanded. Bullectomy and pneumorraphy were then performed successfully.
This procedure is a useful way to determine whether or not compressed lung tissue can be expanded after removal of a bulla.

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