Renal function was tested in 29 patients after pulmonary resection. During the first postoperative week the urine was examined for β₂-microglobulins (u-BMG), which increase with proximal renal tubular dysfunction, and for N-acetyl-β-D-glucosaminidases (u-NAG), which increase when these tubule injury.
In all 29, u-BMG was an abnormally high throughout the week with a peak on the 2nd POD. On the 6-8th POD u-BMG decreased to approximately half the peak level. The u-NAG increased to an abnormal level after the 4th POD, but the increase was slight-only twice the upper limit of normal.
In the high stress group (intraoperative bleeding volume≥1, 000), the u-BMG was still at peak level on the 6-8th POD and the u-N AG level on the 6-8th POD was 5 times the upper limit of normal. Especially in cases with postoperative complications, the levels of both u-BMG and u-NAG increased further on the 6-8th POD.
These results indicate that in cases of pulmonary resection, functional and organic impairment of proximal renal tubules is generally not great. However, with high stress or postoperative complications impairment can be severe and long lasting. Therefore, in these patients, in addition to conventional tests, urinary BMG and NAG should be monitored carefully.

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Since November 1992, we have performed 12 thoracoscopic operations for spontaneous pneumothorax, 10 primary and 2 secondary (tuberculosis and pulmonary fibrosis). In this report, we introduce our operative technique for the treatment of blebs or bullae : coagulation by electric cautery and double continuous sutures. The mean operation time was 80 minutes and the mean period of chest drainage after operation was 2.1 days (max. 3 days). The postoperative course was uneventful, and no recurrence has been experienced to date. An endoscopic stapler is generally used in the thoracoscopic treatment for spontaneous pneumothorax with resection of the lung tissue containing the bleb or bulla. This useful instrument can remove the lesion completely and shorten operation time. However, the specimen cut by stapler tends to be larger than necessary. Moreover, the size and the location of specimens which can be resected by staplers is limited, and the staples can be seen on chest X-ray films forever. We conclude that our operative technique, i. e., coagulation by electric cautery and double continuous suture, is beneficial because this technique is free from such demerits and can be performed at lower cost than resection by endoscopic stapler.

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The definition of early lung cancer remains controversial as to whether the maximal diameter should be less than 1.5 cm. We studied 41 patients with lung cancers with a diameter less than 3.0 cm. The patients were divided into four groups based on tumor size : group I : 0.5-1.5 cm ; group II : 1.6-2.0 cm ; group III : 2.1-2.5 cm ; group IV : 2.6-3.0 cm. The total 5-year survival rate of this series is 55.0%, that of group I, II, III, and IV is 87.8%, 56.5%, 42.0%, and 53.2%, respectively. Clearly, patients with smaller tumors have better survival rates. We also surveyed reports from 20 institutions and found that seven, including our own, reported a 5-year survival rate of 100% for patients with tumors smaller than 1.5 cm without lymph node metastasis. Thus it is reasonable to define early lung cancer as a NoMo tumor less than 1.5 cm in diameter. However, their survival rates of less than 80% were also reported, and numerous patients (23.7%) had lymph node metastases. Thus, it seems more appropriate to draw the border-line of the diameter of “peripheral early lung cancer” with a tumor size of less than 1.0 cm, since this level shows the least metastasis (12.5%) to lymph nodes in the present time.

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We evaluated hilar (# 10) and mediastinal lymph node metastases in primary left lung cancer preoperatively with endoscopic ultrasonography (EUS) and computed tomography in 48 cases from 1988 to 1993. The lymph node areas evaluated with endoscopic ultrasonography were limited to #2, 3p, 4, 5, 8, 10 on the left side and #7. The sensitivities of #10 and #5 were significantly low with computed tomography (50.0% and 28.6%), comparing with those of endoscopic ultrasonography (78.6% and 78.6%). The specificities of #5 and #7 were 82.4% and 81.1% respectively with endoscopic ultrasonography, which were lower than those with computed tomography (91.2%. 94.6%). There was no significant difference in accuracy between the two methods. Both computed tomography and endoscopic ultrasonography should be performed pre-operatively to evaluate lymph node metastasis.

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We performed a randamized study of the effect of ulinastatin on the blood level of granulocytic elastase and on respiratory function after pulmonary resection for lung cancer. Twenty eight consecutive patients who underwent pulmonamy resection for lung cancer were classified into two groups, 13 patients were administered ulinastatin 100, 000 units intravenously just before thoracotomy, followed by a continuous drip infusion of 200, 000 units during surgery and 200, 000 units per day from day 1 to day 4. The other 15 patients were not treated with the agent (control group). To determine the effectiveness of ulinastatin, we examined the following parameters. The serum granulocytic elastase level was measured and blood gas analysis was performed on the day before operation and on postoperative days 1, 3, and 7. The serum level of granulocytic elastase was increased in both groups on postoperative days 1 and 3. A-aD02 and the respiratory index (A-aDO₂/PaO₂) were significantly lower on day 1 in the ulinastatin group than in the control group. We conclude that ulinastatin maintains respiratory function in patients with pulmonary resection for lung cancer.

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From 1972 to March 1993, pulmonary resections were perfomed for 63 pulmonary metastatic tumors, 15 lobectomies and 56 partial resections of the lung. In the partial resections, we used the stapler method in 27 and the Nd : YAG laser method in 29 cases. The rate of postoperative local recurrences in the lung was 51.8 % (14/27) in the stapler group and 3.4 % (1/29) in the Nd : YAG laser group.
The difference is statistically significant (p <0.001). There was no significant difference in the clinical characteristics (age, sex, number of pulmonary metastases, maximun diameter of metastatic pulmonary tumor) or the postoperative survival between the two groups. From the standpoint of local curability, partial resection with Nd : YAG laser is a usefull operative method for pulmonary metastatic tumors.

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We compared the clinical value of pleuropneumonectomy (n=6), extra-periosteal air-plombage (n=6) and decortication (n=7) in patients with pyothorax. There were no significant differences in operation time and postoperative changes of VC among the 3 groups. Blood loss in the extra-periosteal air-plombage group was significantly larger than in the decortication group (p <0.05). Postoperative changes of FEV_1.0, in the pleuropneumonectomy group were significantly less than in the decortication group (p <0.05). Postoperative improvement in Hugh-Jones scores in the pleuropneumonectomy and decortication groups was significantly better than in the extra-periosteal air-plombage group (p <0.05).
These findings indicate that pleuropneumonectomy results in better Hugh-Jones scores, and decortication results in less blood loss and better FEV_1.0 and Hugh-Jones scores.

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Primary resection for lung cancer was performed in 610 patients. Extensive surgery was performed in 146 (23.9%). The operative mortality was 6.2%. In this group the 5-year survival rate was 24.3%. Survival was better in patients with T3 disease (32.2%) than in patients with T4 disease (13.5%) (p <0.05). This was also true in the NO group (31.4%) compared with the N2 group (7 %) (p<0.05). Patients who underwent curative operations also had better survival (32.9%) compared with those who underwent palliative procedures (16.9%) (p <0.01). Better survival was noted in patients who underwent single organ resection (29.3%) compared with those who underwent multiple organ resection (12.7%) (p< 0.05). The 5-year survival of patients who underwent partial resection of the chest wall (n= 100), pericardium (n=37), trachea (n=12), or left atrium (n=16) was 23.6%, 19.7%, 41.3%, and 17.6%, respectively. None of the patients who underwent partial resection of the thoracic vertebrae (n=6), brachiocephalic or subclavian veins (n=6), esophagus (n=4), aorta (n=3), intra-pericardial pulmonary artery (n=3), subclavian artery (n=3), or superior vena cava (n=2) survived longer than 3 years. Twenty-one patients survived more than 5 years. The pathologic staging was T3NOMO (n=10), T3N1M0 (n=4), T3N2M0 (n=1), T3N3M0 (n=1), T4NOMO (n=2), T4N1M0 (n=2), or T4N2M0 (n=1). Histologic examination revealed squamous cell carcinoma (n=12) or adenocarcinoma (n=7) in the majority of cases. Long term survival can be expected in patients with squamous cell carcinoma even with N2 disease. In patients with adenocarcinoma, the prognosis associated with N2 disease was poor. However, six patients with NO or Ni adenocarcinoma survived 5 years.

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A 15-year-old female was found to have an abnormal shadow in the right upper lobe of the lung on a routine chest X-ray before entering senior high school. Several examinations failed to establish a histological diagnosis. Thoracotomy was performed and a frozen section suggested sarcoma. We performed a right upper lobectomy. Immunohistochemical examination revealed leiomyosarcoma of the lung. This case of primary sarcoma of the lung is discussed with reference to the literature on the subject.

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Postoperative bronchial fistula in one of the most troublesome complications of thoracic surgery. We present a case of postoperative bronchial fistula succesfully treated by endoscopic closure with fibrin glue and Nd-YAG laser. A 46-year-old female underwent right lower lobectomy for adeno carcinoma of the lung in November, 1991. A month after postoperative chemotherapy with CDDP and VDS, she developed a bronchial fistula at the resection line of the bronchial stump. We first tried to close the fistula under bronchoscopy with fibrin glue. The attempt was unsuccessful, but 13 days later we were able to close the fistula completely with Nd-YAG laser and fibrin glue. There has been no recurrence for 16 months. We recommend the use of Nd-YAG laser followed by fibrin glue under bronchoscopy to treat the postoperative bronchial fistula when infection is not present.

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A 74-year-old male was found to have an abnormal shadow in the anterior mediasinum. He underwent thymothymectomy in February, 1988. The resected 200 g tumor measured 8 × 7 × 6 cm and was completely encapsulated.
Pathological examination revealed epithelial thymoma with a hemangiopericytomatous pattern. Immunohistochemical examination showed that the tumor cells were stained for keratin and not for factor VIII. The hemangiopericytomatous pattern is rare in patients with epithelial thymoma.

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Three patients, a 49-year-old male, a 58-year-old female, and a 72-year-old, had had intermittent cough and fever for one to 12 years. In their infancy, two of them had had paroxysmal coughing after drinking water. Barium esophagograms revealed that a fistula with an esophageal diverticulum was connected with the right bronchus. At surgery all three fistulas were considered to be congenital, because they had no adhesions or inflammatory features, and exposure was easy. Pathological examination showed that the fistulas and the diverticulum had normal esophageal muscular and mucosal layers without any inflammatory changes. In the former two cases, the fistulectomies and diverticulectomies with the resection of corresponding pulmonary lobes were carried out. The third patient underwent only the fistulectomy and diverticulectomy with no recurrence of aspiration pneumonia.
In conclusion, the fistulectomy and diverticulectomy without any pulmonary resection is recommended as a less invasive surgical treatment.

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A rare case of thymoma with multiple ossifications is reported. A 27-year-old male was found to have a tumor shadow in the left anterior mediastinum on a routine chest X-ray. Despite marked calcification of the tumor shadow, it was difficult to diagnose preoperatively. The tumor was resected on January 29, 1993 for diagnosis and dicision about theraphy. Histological examination revealed that the tumor was an invasive thymoma, epithelial cell dominant type with multiple ossifications. His post operative course was uneventful. No recurrence has been observed during the 12 months since the operation.
In this case, it was difficult to differentiate this tumor from teratoma because of the intense calcification. We consider that the ossification in this tumor may represent an osteoplastic reaction to metaplastic calcification.

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A 59-year-old male had been treated in our hospital since September, 1989 for diabetes, chronic renal failure, and hypertension. The patient has received peritoneal dialysis since January, 1990. In February 1990, chest X-ray revealed a nodular shadow (1.5×1.3 cm) in the left upper lung field.
This was thought to be old tuberculosis and was observed for a while. In March 1991, the enlargement of the nodular shadow (3.0 × 2.7 cm) was noted and the diagnosis of squamous cell carcinoma (c-T2N0M0) was established by transbronchial biopsy.
The patient underwent a left upper lobectomy in June, 1991. Hemodialysis was performed the day before the operation, and peritoneal dialysis was resumed on the day of the operation. Using peritoneal dialysis we were able to sufficiently control postoperative complications. It was recognize that further experience was necessary to know appropriate condition to resume dialysis treatment after surgery.

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A 74-year-old female was admitted because of hypoglycemia. Her chest X-rays revealed an abnormal shadow in the right lower lung field. The blood sugar levels were 41 mg/dl before breakfast and 50 mg/dl before dinner. The values of insulin-related insulin antibody, C-peptide, growth hormone and. cortisol were within normal limits. The chest X-ray films on admission showed a tumor with massive pleural effusion in the right lung. The chest CT scan showed a tumor with calcification and heterogeneous enhancement in the right lower lung field.
At operation, the tumor was found to have a fibrous hard part and a soft part like a bunch of grapes compressing adjacent tissues. The resected specimen was 20×17×15 cm in size and 1200 g in weight. The hypoglycemic attacks disappeared after surgery. After a course of chemotherapy, she was dischared and was doing well without distant metastasis or local recurrence 18 months after surgery.

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A 59-year-old man was admitted because of further examination for a tumorous shadow on his chest X-ray film. Chest CT and MR scanning revealed that the tumorous lesion originated from the left upper lobe and involved the left common carotid artery and the left subclavian artery. A right cerebral angiogram with Matas test during surgery demonstrated the left cerebral arteries speedily and clearly. Followingly, left upper lobectomy with combined resection of the left common carotid artery and the left subclavian artery was carried out. Through the experience of this case, we reconfirm the importance of the Matas test before surgery for the determination of the indication for the resection of the left common carotid artery and the left subclavian artery.

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Castleman's disease arising in mediastinal or hilar nodes is common, but lesions in the chest wall are rare. A 40-year-old male who complained of cough was found to have an abnormal shadow on a chest roentgenogram. Chest CT demonstrated the chest wall tumor as a 7.2 × 4.0 × 3.6 cm homogeneous mass in contact with the posterior pleura at the right 10th intercos-tal space. The CT number of the tumor was 30. MRI T2 weighted image demonstrated the tumor to be a hyperintense lesion. Preoperatively, the tumor was diagnosed as a neurogenic neoplasm in the chest wall. It was resected through a limited thoracotomy with a video-assist. Histopathological examination demonstrated the hyaline vascular type of Castleman's disease. The patient recovered uneventfully, and was discharged 10 days after surgery.

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