In lobectomy using animals, a stepwise gradual increase in the volume of lung resection is encountered by elevation of the pulmonary arterial pressure followed by reduction of the cardiac output, when lung resection exceeds a certain limit in volume.
In a unilateral pulmonary arterial occlusion test, we compared the exercise-loaded cardiopulmonary function with the postoperative cardiopulmonary function.
In consideration of the cardiopulmonary reserve capacity, the physiological safety limit of the lung resection was found to correspond to the total pulmonary vascular resistance of 700 dyne.sec.cm^-5/m² in the contralateral lung.
We usually perform lung resection on lung cancer patients regardless of age, provided that they preserve cardiopulmonary function within the above limit.
However, patients with this safety limit easily develop postoperative lung complication. The upliftment of the safety limit in lung resection is considered to depend on prevention of postoperative lung complication. This paper pointed out that a large number of resectable cases are included in lung cancer patients in whom lung resection is contraindicated for preservation of ventilatory function.

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The postoperative courses in 157 patients with lung cancer were classified into 4 groups : no postoperative problems (Group I, 116 patients), retention of sputum and/or atelectasis requiring bronchofiberscopy more than 2 times (Group II, 17 patients), tracheostomy and mechanical ventilation for more than 2 days (Group III, 14 patients) and postoperative death (Group IV, 10 patients). Pulmonary function study such as FEV1%, MVV/BSA, RL/TLC, ΔN₂% and so on revealed that over the one-third of the patients suffered from chronic obstructive lung disease (COLD) of any degree and the frequency of COLD was significantly high in Group II_IV, compared with Group I.
Predicted postoperative Index (predicted postoperative FEV₁/normal VC) was 56.1+ 15.0% in Group I, 47.1+8.0% in Group II, 31.0+8.4% in Group III and 38.1+16.0% in Group IV, indicating a statistically significant difference between each group except for between Group III and IV.
The postoperative epidural buprenorphine was effective in 90.1% of the patients. Parameters of expiratory function expressed as FVC, FEV1, PEFR, maximum expiratory pressure, cough pressure became significantly better after buprenorphine injection.
The postoperative aminophylline injection (6 mg/kg 30 min) was effective to increase maximum transdiaphragmatic pressure significantly.
We conclude that COLD was an important factor of postoperative risk, and that patients with predicted postoperative Index less than 30% was high risk for postoperative complication. Postoperative epidural anesthesia and aminophylline were useful for postoperative management.

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Various complications occuring after thoracotomy are quite difficult to treat and often lead to death. Of 1, 100 patients undergoing chest surgery in the past five years in our institution, 32 patients (2.9%) died within 3 months : 16 (1.45%) died of cancer and 16 (1.45%) died of complications. Under 50 years of age no patients died of complications. The causes of death due to complications were ARDS (7 cases) from pneumonia, pulmonary thromboembolism (4 cases), postoperative bleeding (2 cases), cerebral bleeding (1 case), renal failure (1 case) and gastro-intestinal bleeding (1 case). The values of total pulmonary vascular resistance index at the unilateral pulmonary arterial occlusion test in 3 cases of these were over 690 dyne.sec.cm^-5. Symptoms of postoperative pulmonary thromboembolism were similar to those of other complications. To diagnose this complication, subselective pulmonary angiography using a baloontipped catheter at the bedside was useful in patients who were incapable of being moved for severe condition.

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Four hundreds and fifty-one patients with bronchogenic carcinoma underwent pulmonary resections from 1965 to 1985. Postoperative pulmonary complications were analyzed in this paper. The procedures performed were lobectomy in 268 patients (59%), lobectomy with bronchoplasty in 59 (13%), bilobectomy in 45 (10%), Pneumonectomy in 33 (7%), and segmentectomy in 27 (6%).
Sixty-six patients (15%) had postoperative pulmonary complications. Seven patients died from pulmonary complications after operations and twelve died after 30 days in the hospital.
The major complications observed were prolonged alveolar air leakage in 15 patients, atelectasis in 11, pneumonia in 10, and bronchopleural fistula in 9. Infectious diseases such as pneumonia and bronchopleural fistula caused high mortality. The risk factors were identified to be old age over 70 years, operative procedures of lung resections other than lobectomy. restricted pulmonary reserve, the need for combined resections of neighbouring organs, and non-curative operations.
To decrease the incidence of the postoperative pulmonary complications for the patients with bronchogenic carcinoma, careful preoperative evaluations of cardiopulmonary reserve, routine physiotherapy and precise postoperative care are important.

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From 1962 to 1986, 1838 patients underwent surgery for carcinoma of the lung. Postoperative pulmonary complications were analyzed, and was discussed about the prevention and the treatment of complications. Major risk factors of complications were old age over 70 years old, pneumonectomy and preoperative chemotherapy or radiation. Before 1980 8.7% of patients had complications and 3.8% died following surgery, on the other hand after 1981, although 11.7% had complications only 1.5% died. Patients of 70 years of age or older are increasing, and after 1981 25.8% were 70 years of age or older. The rat of complications in this group of case was 14.9%. In pneumonectomy cases 21.5% developed complications. The main pulmonary complications of all cases were pneumonia, respiratory failure and prolonged parenchymal air leakage. In recent years the incidence of bronchopleural fistula, pulmonary edema and lung abscess decreased. Postoperative pneumonia continued to be a major cause of mortality. Pseudomonas aeruginosa, Klebsiella pneumoniae and Streptococcus viridans were the main pathogens associated with pneumonia. To prevent pneumonia and to maintain the trachea and bronchus clear the bronchofiberscope was frequently used during surgery and in the postoperative period. To prevent pneumonia due to aspiration we used a double lumen tube during thoracotomy and we frequently performed sputum bacteriological examination in the postoperative period. In all cases epidural injection of 2-4 mg morphine were given for postoperative pain relief. In case of combined and wide resection of the anterior chest wall, reconstruction of the chest wall with homogenous bone graft was effective in preventing the development of respiratory failure. Recently, 25 case receiving “neoadjuvant” chemotherapy, i.e. chemotherapy performed preoperatively in those cases in which the initiated indications of surgery were unclear-surgery-enabling chemotherapy, underwent surgery for carcinoma of the lung. This group of patients showed somewhat different tendencies from other cases in terms of their postoperative course. The low incidence of complication observed was attributed to careful preoperative evaluation, selection of the appropriate surgical procedure nd inclusion of careful management of patient in the perioperative period.

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Thirty-four patients with malignant tumors of the thymus were surgically treated during the 15 year period from 1972 to 1987.
Of twenty-two patients with invasive thymoma, the tumors were successfully removed in fourteen patients by using the technique of the combined resection of SVC. Of two patients with carcinoid, one is alive and another died two years after extended operation. Of two patients with Hodgkin's disease of the thymus were alive with the tumor bearing. Of eight patients with the malignant germ cell tumor, three of four patients with seminoma have been well for 14, 6 and 2 years. Chemotherapy and radiotherapy were effective on their long survivals. Three patients with embryonal carcinoma responded well to combined surgical and chemo-radiotherapy. But only one of them is alive with tumor free four years after operation. One patient with malignant teratoma did not responded well to combined therapy and died 1 year after operation.
In conclusion, aggressive surgical removal followed by chemo radiotherapy offers the best cure of the malignant tumors of the thymus.

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One hundred forty-two patients with surgically treated thymoma were studied on how the complete resection of the tumor influenced on the survival rate in terms of the clinical stages and histological cell types. The survival rates of stage I disease (45 patients) undergoing a complete resection were 100% for 5 and 10 years, and 85.7% for 15 years. Those of stage II disease (33 patients) undergoing a complete resection were 91.5% for 5 years, 84.4% for 10 years, 70.4% for 15 years, and in stage III disease (35 patients) they were 100% for 5 years, 94.7% for 10 and 15 years. Thus, there were no statistically significant differences in survival rates of patients with stage III disease undergoing a complete resection compared with patients with stage I and II diseases. On the other hand, survival rates of stage III disease (5 patients) undergoing a subtotal resection were 80% for 5 and 10 years, 0% for 15 years, and also, those of stage IV disease (13 patients) undergoing a subtotal resection were 62.3% for 5 and 10 years. There were no significant differences between survival rates of stage III and IV diseases undergoing a subtotal resection. Also, concerning the histological cell types, there were no significant differences of survival rates between patients undergoing a complete resection.
In conclusion, even in invasive thymoma invading the surrounding tissues (stage III), if it is removed completely, the prognosis in the long term is comparable with non- or minimally invasive thymomas, irrespective of the histological cell types.

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Malignant germ cell tumors of mediastinal origin can be classified as to seminomas and non-seminomatous germ cell tumors (NSGCT) just as of testicular origin. The former are generally highly sensitive to radiation therapy, and then can be expected of relatively better prognosis. The latter generally have a low sensitivity to radiation therapy, and have been expected so far to have a quite poor prognosis even after the introduction of multi-drug chemotherapy based on cis-platinum (CDDP). In this paper, we analysed on 16 cases of mediastinal malignant germ cell tumors of our own with reference on the literature, leading to the following working guideline for the management of those tumors.
1. When there is a suspicion of a malignant germ cell tumor, diagnostic assessment should be made through CT, serum markers such as AFP and HCG, and if necessary through biopsy.
2. When either of the markers is positive, or histological diagnosis is determined through biopsy as a malignant germ cell tumor, first choice to do is CDDP based chemotherapy in an attempt for the tumor to be completely resected at the subsequent surgical treatment.
3. When neither of the marker is negative and the tumor is expected to be surgically completely removed, operation is to be forwarded.
4. Following operation, either chemotherapy, radiotherapy, or their combined therapy is to be added by necessity.

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A total of 12 cases of anterior mediastinal germ cell tumors observed in our laboratory for 30 years from 1957 to 1986 were classified into 6 types according to the additionally modified Dixon and Moore's classification and the therapies and prognoses of each type were investigated and the following results were obtained.
1. There are various nomenclatures used to describe germ cell tumors in anterior mediastinum and their classification has not yet been established, therefore our classification seemed practically useful in the surgical clinical field.
2. In the cases of Type II (embryonal carcinoma pure, or with seminoma) and VI (yolk sac tumor) prognoses were extremely resistant to treatment whereas that of Type III was satisfactory.
3. AFP and hCG used as a tumor marker were very useful as an indicator for chemotherapeutic effectiveness and the recurrence of postectomy, and the immunohistochemical study of ectomized tumors was inevitable which was useful for postoperative classification and therapy.
4. Prolonged survival can be expected by combining radiotherapy with operation in the treatment of Type III. Furthermore, it is desirable to additionally perform chemotherapy after operations when a positive picture was found immunohistochemically.
5. For the patients with germ cell tumors producing AFP, adjuvant surgery was applied after chemotherapy using cisplatin as a main agent, then the prognostic convalescence of the difficult anterior mediastinal germ cell tumors could be predicted.

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In a series of 52 malignant thymic tumors at our institution between 19751986, there were 34 thymomas, 4 thymic carcinomas, 5 germ cell tumors, 1 thymic carcinoid, 1 thymic malignant fibrous histiocytoma, and 7 malignant lymphomas.
Aggressive surgical resection of tumors combined with chemotherapy and/or irradiation were tried to perform for these tumors. Thymomas, thymic carcinomas, and a thymic carcinoid seem to be good after the treatment.
On the other hand, germ cell tumors and malignant lymphomas seem to be not good. Treatment effects for complications of thymomas were not satisfactory except for myasthenia gravis. Localized recurrences could be managed by surgical resection and/or irradiation, and W-CT is a useful examination to detect recurrences of tumors at early stage.

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Twenty-seven cases with invasive thymoma were treated with surgery and/or radiotherapy. Twenty-six of them consisted of 9 stage II, 11 stage III and 6 stage IV a tumors by Masaoka's classification, while remaining one had recurrent tumors. All cases of stage II were treated with resection only; and there has been no recurrence of tumors. Among stage III patients, all 4 patients treated with local irradiation and 2 of 3 treated with only resection were deceased from the recurrence of tumors. The remaining 4 stage III patients were treated with entire hemithorax irradiation after resection, all of whom are alive and free from relapse for 13 to 81 months. Two stage IV a patients treated with entire hemithorax irradiation of 20 Gy suffered from recurrent pulmonary infections secondary to irradiation pneumonitis. In 2 of stage IV a cases and relapsing one, intensive chemotherapy (CHOP) before radiotherapy up to 15 Gy including entire hemithorax was performed, which proved quite recommendable because all 3 patients are alive and well with no pulmonary complications or relapse for 9 to 15 months.

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This 40-year-old man receiving medical treatment for myasthenia gravis, demonstrated a mediastinal mass shadow and multiple tumor shadow at left lung field, suggesting invasive thymoma with pleural-dissemination.
On March 22, 1985 operation was performed. At first median sternotomy was made and extended thymectomy was done, and successively left postero-lateral thoracotomy was made and left panpleuro-pneumonectomy was carried out.
At present after two and a half years following the operation, he is working without recurrence of thymoma, and symptoms of myasthenia gravis is under control by the administrative 10 mg/day of prednisolone.

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Massive hemoptysis is a major clinical problem and may present life-threatening situation in patients with chronic pulmonary diseases. Surgical resection has been the procedure of choice in this kind of patients. But, frequently they are not candidate for surgical procedure because of poor pulmonary function, wide-spread lesion and so on. Catheterization and arterial embolization (BAE) have been used successfully to arrest massive and recurrent hemoptysis. But, BAE is a palliative treatment because the primary cause of hypervascularity remains within the lung, and recanalization and revascularization may occur due to collateral circulation and reabsorption of embolized materials. Also another major risk of BAE is spinal cord injury because of existence of anterior spinal arteries seen on preliminary arteriogram.
Surgical ligation and resection of bronchial arteries without pulmonary resection have been performed in 4 patients, in whom preliminary arteriogram revealed anastomoses between anterior spinal arteries and bronchial arteries. As for complications caused by bronchial artery ligation, neither spinal cord injury nor any other side effect or recurrence was seen. However, spinal cord injury occurred in one patient as a result of BAE. This complication can occur even in cases in which no significant blood supply to the spinal cord can be seen on preliminary arteriogram.
The possibility of controlling massive hemoptysis by ligation of bronchial artery and other feeding arteries may be worth consideration, especially in patients with advanced pulmonary insufficiency who are not incapable to pulmonary resection, in relapsed cases after BAE and in those with arterial feeding anastomoses of the spinal cord seen on preliminary arteriogram.

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Twenty-nine patients with hemoptysis were studied. Fifteen patients underwent operations. Eight were treated with bronchial arterial embolization (BAE) alone. Six died of large amount of hemoptysis, among which four had a hemorrhage from postoperative bronchopulmonary arterial fistula. Among operated patients, eight underwent preoperative BAE. Six patients made unfavorable results, among whom two underwent emergent operations. One patient was treated with four times BAE alone during five years seven months period. Follow up interval of five patients with single BAE does not reach two years. They require longer observation. Relative indications for operation are effective BAE, confined lesions or marked organic change. Absolute indication is in the case of ineffective BAE when patient's general status permits operative burden. Hemorrhages from bronchopulmonary arterial fistalas require emergent operation, however, most cases are fatal.

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Persistent intratracheal bleeding is one of the most dangerous conditions in patients with severe blunt thoracic trauma, because patients may be asphyxiated in their own blood. Since 1981 we have used Endotracheal Tube with Movable Blocker (UNIVENT) to separate the bleeding lung from non-bleeding lung in eight patients with continuous intratracheal bleeding. The progression of acute respiratory failure could be prevented in all patients by this treatment combined with well controled mechanical ventilation.
Four patients underwent the resection of bleeding lung a few hours after the separation of lung with UNIVENT. Two patients survived but other two patients died of the associated brain contusion on the sixth and eighth postoperative day.
Remaining four patients were observed closely and waited until intratracheal bleeding stopped spontaneously. It took 8, 20, 36 hours and six days respectively to fulfil the purpose. One patient needed thoracotomy thereafter to control the persistent intrathoracic bleeding. All four patients survived.

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23 cases of airway bleeding due to causes other than lung cancer were treated surgically over a period of 10 years.
Average age was 50 years-old.
Male-female ratio was 15 : 8.
Maximum volume of bleeding in a day; less than 50 g : 11, 100-200 g : 8, more than 500 g : 4. Diseases were; 3 total pyothorax, 1 partial pyothorax, 2 tension-hemopyothorax, 4 tuberculous destroyed lungs, 3 bronchiectasis, 1 silicotic tuberculosis, 1 broncholithiasis, 1 aspergillosis, 1 intrapulmonary foreign body, 2 tiny tuberculous foci, 3 idiopathic airway bleeding, 1 pulmonary rupture of the chest wall angiosarcoma.
More than 80% of the cases were tuberculosis or tuberculosis-related diseases. Surgical procedures were ; Pleuro-pneumonectomy : 6, Pneumonectomy : 4, Lobectomy : 6, Segmentectomy : 1, Empyema-space reduction : 1, Closure of the intermediate bronchus : 1. Operative positions; Prone : 13, Lateral : 8, Supine : 2. Preoperative hemostasis was tried in 3 cases and all failed.
Operations were successful in 20 of the 23 cases. We advocate direct surgical procedure for hemoptysis cases if the bleeding foci are apparent and the patients have sufficient respiratory reserve.

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Since April 1977, systemic artery embolization was performed to control hemoptysis with use of gelform on 66, and stainless steel coil on 21 patients. Recurrence of hemoptysis within one year was noted in 18 patients out of 54 gelform cases and six out of 21 coil cases. Most often found on following angiography was recanalization in gelform cases, another unembolized systemic artery, intercostal or bronchial in coil cases whether or not hemoptysis recurred. Hemoptysis recurred in higher incidence in active tuberculosis and pulmonary mycosis, and the incidence was 4 out of 7 active tuberculosis, and 3 out of 4 mycosis, comparing with that of old tuberculosis or bronchiectasis, that is 6 out of 20 and 4 out of 14 respectively.
Twelve patients underwent surgical resection after embolization successfully, especially when surgery was done within two weeks. Pneumonectomy was required only in two cases according to the extent of diseases. Lobectomy was the most often performed mode of operation which was done on 9 cases. In one case segmentectomy was the satisfactory resection.
As for the complication of the embolization no spinal cord injury was noted in this series of cases, even when intercotal arteries were embolized intentionally. (Author's)

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48-and 96-hour lung preservation were conducted using simple cooling method in dogs. The effect of buffer action of solutions to the lung preservation was examined.
Phosphate buffered solutions with 2% of low molecular weight dextran (Ep₁Ep₃) were prepared with the change of pH by altering the ratio of H₂PO₄-and HPO₄^2-. In Ep₄, K₂HPO₄ was added for considering its availability to the heart-lung preservation. As to the electrolyte composition, all solutions were prepared as the extracellular fluid. For preservation, heart-lung bloc of the donor was used. After completion of the preservation, left lung was removed from the heart-lung bloc and transplanted to the recipient orthotopically. Recipient was immunosuppressed using 100 mg/day of azathioprine and 100 mg/day of methylprednisolone for 7 days after transplantation, thereafter each drug was decreased to 50 mg/day in dosage. Serial chest X-ray films were taken after transplantation. Contralateral pulmonary artery ligation was conducted on 11th day postoperatively in the successful cases.
4 out of 4 (100%) were successful transplants after 48-hour preservation using Ep₃ solution with the pH resembling to the physiological pH at 37°C. In 96-hour preservation, 3 out of 4 were successful cases, however, they did not give satisfactory results on chest X-ray films, contralateral pulmonary artery ligation and histologic findings comparing to successful cases in 48-hour preservation group. Further improvement in preservation solution is considered to be needed for 96-hour lung preservation.
From this experiment, we concluded that our method of lung preservation using Ep₃ solution may be reliable for 48-hour lung preservation in human lung transplantation.

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An experimental study on canine lung transplantation was performed, comparing intra cellular enzyme activity of the peripheral lung tissue with histological findings. Before morphological damage could be recognized, enzymological cellular damage of lung tissue was demonstrated. In particular, lysosomal enzyme activity was considered to be one of primary factors associated with lung tissue injury under conditions of warm ischemia.
In order to estimate the revascularization of the bronchial anastomosis and the rejection process in canine lung transplantation, we performed fluorescein assisted endoscopic bronchial imaging (FEBI) following bronchoplasty and lung auto-and allotransplantation. In cases of bronchoplasty there was no difference in the time required for complete revascularization of bronchial anastomosis between autotransplantation and dogs undergoing allotransplantation and treated with cyclosporine. Bronchial mucosal revascularization was confirmed 14 to 21 days postoperatively. In allotransplanted dogs in which rejection was later recognized the absence of fluorescein from the bronchial mucosa in sub-sub segmental bronchi after FEBI suggested damage to the vascularization in that lesion and, by extension, implicated this vascular system in the rejection phenomenon.

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