Using Assess Peak Flow Meter, we measured the changes in the peak flow rates (PFR) in the early and late postoperative phases in 12 patients after lung resection. Six patients received epidural anesthesia during the early postoperative phase.
In those without epidural anesthesia, PFR in the early postoperative phase decreased to 1/ 3 of the preoperative value, and then recovered to 77% of the preoperative value. Two patients without epidural anesthesia developed atelectasis, and their PFR values were lower than 100 L · min^-1.
The decrease in the PFR in the early postoperative phase was significantly suppressed by epidural anesthesia. None of the patients with epidural anesthesia suffered from atelectasis.
The PFR values on the 28th postoperative day correlated well with the preoperative values times the residual pulmonary vascular perfusion fraction rate product.
In conclusion, the decrease in the PFR in the early postoperative phase is suggested to be one of the causes of postoperative pulmonary complications, and epidural anesthesia during the early postoperative phase may be useful in postoperative respiratory management.

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Twelve operations for lung cancer in patients with bullous disease were performed from April, 1974 to June, 1994. Eleven were males and one was a female. The average age was 57 years. All the male patients were heavy smokers. In nine patients there was a giant bulla adjacent to the cancer. It was difficult to make a definite diagnosis before operation, so it is important to perform the biopsies via thoracotomy to confirm the roentgenographic diagnosis. The tumor was in the right upper lobe in seven patients, in the right lower lobe in three and in the left upper lobe in two. Nine patients were treated with lobectomy, one with lobectomy plus resection of a vertebra and one with lobectomy plus resection of the chest wall and one with exploratory thoracotomy. Histological examination showed adenocarcinoma in seven (58 %), large cell carcinoma in three (25%), squamous cell carcinoma in one and undifferentiated carcinoma in one. The majority had poorly differentiated carcinoma. The postoperative diagnosis was Stage I in six, IIIA in two, IIIB in two, and IV in one patients. It appears that the prognosis for lung cancer associated with bullous disease is better surgical treatment is performed early.

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Video-assisted thoracoscopy was performed in a total of 56 patients in our institute between August 1992 and December 1994. The indications for thoracoscopy were pneumothorax (26 cases), mediastinal and chest wall tumor (10 cases), postoperative lung fistula (2 cases), hyperhidrosis (1 case), diffuse lung disease (11 cases), small pulmonary nodule (5 cases), and pleuritis (1 case). Thoracoscopy was used therapeutically for spontaneous pneumothorax, mediastinal and chest wall tumor, postoperative lung fistula, and hyperhidrosis. The outcome was very good except in three patients with pneumothorax who required thoracotomy. Thoracoscopy was useful especially in the diagnosis of diffuse lung disease, small pulmonary nodules and pleuritis. Recent advances in endoscopic equipment and refinement of thoracoscopic techniques and increased experience with thoracoscopy have expanded the application of this procedure. Our experience indicates a markedly expanded role for thoracoscopy in the diagnosis and treatment of thoracic diseases with less postoperative morbidity.

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Problems occurring during thoracoscopic resection of the lung were analyzed in 25 patients with peripheral pulmonary nodular lesions. The tumor could be successfully resected with the use of an ENDO GIA30 in 24 patients (96%). Histopathological examination showed no tumor cells remaining in the stump. In all the successful operations, the tumor diameter was 3 cm or less, and the distance from the pleura or the interlobular surface of the lung to the tumor, as assessed by CT scans, was 2 cm or less. It is therefore concluded that these two parameters are important for complete resection of nodular lesions with an ENDO GIA30. The identification of the location of the lesions was easy in 17, difficult in 6 and impossible in 2 patients. Determination of the location of nodular lesions was difficult when the tumor was metastatic, as small as 1 cm in diameter, or located 16 mm or more from the pleura or the interlobular surface as assessted by CT scans. Prolonged air leakage was observed in 4 patients ; 3 with COPD and 1 with metastatic lung cancer following pneumonectomy. Thoracoscopic resection of the lung with an End-GIA alone does not appear completely satisfactory in patients with COPD.

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It has been well established clinically that total pulmonary vascular resistance (TPVRI) during the unilateral pulmonary arterial occlusion test (UPAO) is a useful marker in the evaluation of the resectability of lung tissue. To clarify this concept physiologically, we determined pulmonary circulation properties in patients with high TPVRI during UPAO, by evaluating blood flow-pressure relationships. We performed selective and unilateral pulmonary arterial occlusion tests (SPAO and UPAO) and calculated pulmonary vascular resistance per segment (PVRIsegment) with the aim of reestablishing pulmonary circulation in unoccluded pulmonary segments. There was no difference between SPAO and UPAO results in PVRIsegment in patients with TPVRI over 700 dyne · sec · cm^-5 · m², but is patients with TPVRI under 700 dyne · sec · cm^-5 · m² there was a significant decrease at both SPAO and UPAO. This indicates a decrease in the compliance of the remaining pulmonary vascular bed. We conclude that the pulmonary circulation in patients with a high TPVRI during UPAO can be characterized as having lost elastic capacity with increasing pulmonary blood flow.

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From January 1988 to December 1994, 15 patients with double primary cancers involving both the lung and the gastrointestinal (GI) tract underwent surgical resections of both lesions. These patients represented 13.5% of the 111 patients with primary lung cancer who had resections during the same period. There were 14 men and one woman. The mean age of the patients was 68.7 years (range, 56 to 77 years). Double primary cancers were synchronous in 8 and metachronous in 7 patients. One patient had triple cancers. The most common site of associated GI tract cancer was the stomach (8 patients), followed by the colon (4), rectum (2) and esophagus (one). The lung cancers were 7 adenocarcinomas, 5 squamous cell carcinomas, 2 large cell carcinomas and one small cell carcinoma. The patients with pulmonary adenocarcinoma had associated GI tract cancers distributed from the upper to the lower GI tract, whereas in the patients with pulmonary squamous cell carcinoma, all double cancers were in the upper GI tract. During follow-up 5 patients died of lung cancer and 3 died of GI tract cancer. The survival rate was 62.2% at 3 years and 41.5% at 5 years.
In patients with primary lung cancer, the incidence of associated GI tract cancer, especially stomach cancer, is high. So, it is important to examine and follow up these patients with special attention to the GI tract in order to improve the survival of lung cancer patients.

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We determined the number of mediastinal lymph nodes confirmed by mediastinoscopy, which we could excise in patients with left lung cancer, and we called it the excision rate. We divided the patients into two groups : in group A the aorta was mobilized and Botallo's ligament was incised when we excised mediastinal lymph nodes (n=4); in group B only Botallo's ligament was incised (n=9). There were no significant differences between the two groups in the excision rates of node #2, left #4 and #7. The excision rate of node #3 in group A was significantly higher than that in group B.
These findings indicate that mobilization of the aorta and incision of Botallo's ligament should be done when we excise mediastinal lymph nodes in patients with left lung cancer.

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A 13-year-old boy with progressive neurological disease underwent tracheostomy for the management of pneumonia. A massive tracheal hemorrhage occurred suddenly 21 days later. The bleeding was controlled with a hyperinflated cuff of the tracheostomy tube, and an emergency operation was performed.
A 2 cm length of innominate artery including a fistula 4 mm in diameter was resected and replaced with an e-PTFE graft 8 mm in diameter. The tracheal fistula was closed directly with absorbable sutures with pericardial pledgets, and the suture line was wrapped with the thymus. Reoperation was performed for mediastinitis on the 7th postoperative day. The graft was removed and the suture lines of the arteries were covered with the major pectoral and the sternocleidomastoid muscles. The mediastinitis persisted for 4 months after the second operation, but it was finally cured.
From our experience and review of literature, we conclude that resection of an innominate artery fistula and direct closure of the tracheal fistula are the best method of treatment and that if an artificial graft is necessary, it should be placed through the extra-mediastinal space, since mediastinitis may occur postoperatively.

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A 47-year-old female who had had progressive systemic sclerosis (PSS) for 18 years was referred to our hospital because of increasing dyspnea. A chest X-ray and CT scan revealed a mass in the right lower lobe and bilateral pulmonary fibrosis. Biopsy by bronchoscopy showed adenocarcinoma of the lung. Right lower lobectomy with partial resection of the right diaphragm was performed. Histological examination showed moderately well-differentiated adenocarcinoma, T2N1M0 Stage II. The patient's postoperative course was uneventful. Most cases of lung cancer associated with PSS are inoperable due to the far advanced stage or poor pulmonary function. Attention should be paid to the management of patients with PSS, keeping in mind its possible association of lung cancer.

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A 62-year-old man was admitted because of an abnormal shadow on a chest roentgenogram. Computed tomogram revealed an oval high density mass, 4.0 × 3.0 cm in size, in the peripheral portion of S¹⁰ of the right lung just beneath the pleura. The serum α-fetoprotein (AFP) was moderately elevated to 186 ng/ml, with affinity to concanavalin A of 12%. Other tumor markers, CEA, CA19-9, SCC antigen and HCG were within normal limits. The serum AFP level decreased rapidly after right lower lobectomy. The tumor was diagnosed as adenosquamous carcinoma, t2, nl, m0, stage II, and several cancer cells growing in an adenocarcinoma pattern were positive for AFP immunohistostaining. Forty-five literature cases plus present case of AFP-producing lung cancer were analyzed. There were 42 men and 4 women with a mean age of 67 years. The serum AFP level varied from 73 to 309, 530 ng/ml. The most common histologic diagnosis was adenocarcinoma (67%), especially poorly differentiated type. AFP-producing adenosquamous carcinoma of the lung is rare ; this report is considered to be the second in the literature.

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Thoracotomy technique for extrapleural pneumonectomy to treat diffuse pleural mesothelioma is described. The standard posterolateral skin incision is prolonged along the anterior costal arch, and thoracotomy is performed through the 5th intercostal space following division of the 6th and 7th costal cartilages. This approach provides an improved wide operative field and allows easy resection of the parietal pleura, especially with the diaphragm.

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A 19-year-old man was referred to our hospital because of an abnormal routine chest roentgenogram on July 1, 1993. Further examinations led to the diagnosis of paraesophageal congenital cyst. Thoracoscopic removal was performed on October 15. The histological diagnosis was bronchogenic cyst. Paraesophageal bronchogenic cysts are rare.
It is difficult to differentiate bronchogenic cysts from esophageal cysts both by histologically and radiologically. Thoracoscopic surgery is becoming increasingly popular, and we used it to remove this paraesophageal cyst.

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Lung transplantation has become established in Western countries as one of the last options for treatment of the end-stage pulmonary diseases. For patients with primary and secondary pulmonary hypertension, lung transplantation is also a good treatment. A 16-years-old Japanese high school boy with severe primary pulmonary hypertension underwent bilateral lung transplantation in the United States. Three months after transplantation, he return to our hospital in good condition, and he has been well without any signs of rejection, infection or other complications.

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A 64-year-old man was admitted to our hospital because of back pain and a tumor located from the 2nd and 3rd ribs to the 2nd and 3rd thoracic vertebrae. A tumor biopsy stained immunohistochemically cytokeratin showed anaplastic carcinoma, but whole body examination failed to demonstrate the primary site. The diagnosis was vertebral metastatic carcinoma of unknown origin. Preoperatively 40 Gy radiotherapy was administered. We resected the tumor, chest wall and 2nd and 3rd thoracic vertebrae, and inserted a prosthetic replacement. No viable tumor cells were detected in the resected specimen. During the 15 months of observation after the operation vertebral stabilization was well maintained and no recurrence or metastasis was noted.

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A 76-year-old man was admitted to our hospital with shortness of breath on exertion after open thoracotomy for spontaneous pneumothorax. A CT scan revealed diffuse paraseptal bullous emphysema of both lungs. The right lung surface was coagulated and shrunken by contact Nd : YAG laser (810 W). Air leakage persisted for 10 days, but the postoperative course was uneventful. By 3 months after surgery, forced expiratory volume in 1 second % was increased from 32.2% to 43.2%, residual volume was decreased from 186% to 173%, maximal oxygen intake was increased from 876 ml/m to 1124 ml/m, and there was less dyspnea. Thoracoscopic lung surface coagulation with Nd : YAG laser may be effective in the treatment of bullous emphysema.

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