Ten patients treated for chylothorax from 1975 to 1990 were reviewed. The etiology was traumatic in seven patients and idiopathic in three patients. Their ages ranged from 30 to 66 years.
All the traumatic chylothoraces occurred as a complication of thoracic surgery : lung cancer (five patients), esophageal cancer (one) and mediastinal leiomyoma (one). The maximum chyle loss per day ranged from 150 to 1650 ml (2.4 to 36 ml/kg), and the mean flow rate of chyle from 0.1 to 1.5 ml/kg/hour. One patient recovered with conservative treatment. Six patients recovered with surgical treatment. Early operation is indicated if maximum chyle loss per day exceeds 17 ml/kg.
The three patients with idiopathic chylothorax were female. Two patients had bilateral chylous effusions and one had left-sided chylous effusion. One patient with bilateral chylous effusions, who was actively treated with thoracotomy, intravenous hyperalimentation and continuous intrapleural tube drainage, is alive 6 years and 7 months after thoracotomy. But the other patient with bilateral chylous effusions, who was treated conservatively with low-fat diet, intermittent aspirations and pleurodesis, had severe restrictive ventilatory impairment and died 3 years later. Even if a chylothorax is idiopathic, we should examine the patient carefully and treat him surgically before conservative treatment causes restrictive ventilatory impairment.

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For the pain relief after thoracotomy, the epidural injection of buprenophine was performed in 57 cases. The effect was excellent in 34 cases, who were free from pain without any other medication, and good in 18 cases, who sometimes felt dull pain and had another analgetics. This method was estimated as effective in both of them (52 cases, 91.2 %).
More of the effective cases were observed in the group receiving the analgetics before awaking from anesthesia than in the group receiving after returning to the ward (p <0.05).
To evaluate the analgesic effect, the respiratory rate of this group was compared with that of the intramuscular injection group in postoperative 24 hours. It was 7.9±3.6 breaths/min for the excellent effective epidural group, which was significantly lower than 12.7±5.0 breaths/ min for the latter group (p <0.001).
It was concluded the epidural injection of analgetics had the stable analgesic effect after thoracotomy, especially in the group receiving medication before awaking from anesthesia.

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Six patients with mediastinal tumors (2 neurogenic tumos, 2 mediastinal goiters, 1 lymphan-gioma and 1 anaplastic carcinoma) were examined preoperatively by esophageal ultrasonogra-phy (EUS).
The EUS probe was inserted orally into the esophageal lumen, and a visual longitudinal image of the mediastinum was obtained.
All six tumors were depicted, and their locations were identified by the surrounding struc-tures, i. e. the heart and the great vessels. Moreover, the finer characteristics of each tumor, encapsulated or invasive, solid or cystic were determined by the EUS.
EUS proved to be of value in evaluating upper-, middle-, or posterior mediastinal tumors preoperatively.

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Kitasato University School of Medicine, Kanagawa, Japan From 1978 to 1988, we treated nine patients with traumatic tracheal and tracheobronchial injury. Three patients died from associated injuries, such as injuries of the heart, mediastinal vessels, spinal cord or abdominal organs.
Suture repair was performed in two patients.
One had penetration of the cervical trachea, and the other had laceration of the right main and intermediate bronchus.
Lacerations of the left lingual bronchus were diagnosed by fiberoptic bronchoscopy in three patients. They were treated nonoperativery without complications.
With more carful examination by bronchoscopy, injury of the distal airway can be found much more frequently than previously expected.

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A 44-year-old man, with no complaint, was admitted to our hospital because of a cystic mass located in the right superior mediastinum. Routine blood chemistry studies revealed no abnormality.
In February, 1990 an operation was performed through a midline sternotomy. A thin-walled cyst (15 × 7 × 3 cm), located behind the superior vena cava and to the right of the trachea, contained 150 ml of clear colorless fluid. It was removed en bloc with the right lobe of the thyroid gland. The postoperative course was uneventful.
Histological examination showed a cyst lined throughout by a monolayer of cuboidal epithelium. The cyst wall consisted of parathyroid tissue.
Mediastinal parathyroid cyst is very rare. Since the first case reported by DeQuervain in 1925, only 30 cases have been reported in the literatures. These are reviewed here.

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Subcarinal injection of 20KE of OK-432 for the lung cancer patients was performed with bronchofiberscope at 4-10 days before thoracotomy. 51Cr-release assay of resected lymphnode cells at operation was carried out with or without IL-2 stimulation.
Although LAK activity with IL-2 stimulation was not detected with or without OK-432 administration, stimulation of lymphnode cell activity was demonstrated when it was measured without IL-2 stimulation. Metastatic lymphnode cell activity was reduced, when it was measured with IL-2 stimulation.

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Sixty five patients with impaired pulmonary function (FEV_1.0≤ 1.5 _l) received pulmonary resection for lung cancer in our hospital during the past 13 years (1977 to 1990). A retrospective review revealed that FEV_1.0 is one of the important factors in evaluating postoperative course.
Patients with lower FEV_1.0 were more likely to have pulmonary complications, to require tracheostomy and artificial respiration, and to stay in the ICU longer, but most of the patients recovered with intensive respiratory care. FEV_1.0 had no influence on the mortality rate.
Three of 4 patients with markedly impaired pulmonary function (FEV_1.0≤ 0.7 _l) could be discharged from the hospital after lung resection. One of the patients, who was a wet case, died from pulmonary complications.
Even patients with impaired pulmonary function can receive pulmonary resection for lung cancer, if they are not wet cases, and can recover with intensive respiratory care.

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From January, 1976 through December, 1989, 12 patients with pulmonary aspergillosis underwent surgical treatment, 11 had intrapulmonary and one had intrathoracic legions. Six had abnormal shadows on routine chest X-ray examination. Six patients had symptoms; bloody sputum in 3, hemoptysis in 2, pneumothorax in 1. Two patients had tuberculosis, 2 diabetes mellitus, one bronchiectasis. In the patient with intrathoracic aspergilloma, right upper lobectomy had been performed previously because of tuberculosis. Lobectomy was performed in 6 patients, segmentectomy in 3, partial resection in 2. The intrathoracic aspergilloma was initially treated by transcutaneous infusion of amphotericin B, but no change was noted in the cavity, so an omental flap plombage following cavernotomy was conducted. The post operative course was uneventful. Aspergilloma should be resected when the differential diagnosis from lung cancer is difficult and medical treatment is ineffective. For intrathoracic aspergilloma with bronchopleural fistula, omental flap plombage is the best treatment.

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CT-guided fine needle aspiration biopsy (CT-FNAB) was performed in 13 patients, because it was difficult to obtain diagnostic material by bronchofiberscopic or fluoroscopic biopsy. The age range was 22 to 76 year (average 56.2); 10 were male and 3 were female. The tumor size was 15 to 30 mm (average 25.3 mm). We used the Sure-cut needle (21 gauge). In the 13 patients with small pulmonary nodules, 11 cases of lung cancer were confirmed by needle biopsy (100 %; 11 out of 11 cases), and 2 cases of hamartoma were confirmed by surgery.
Of the 11 lung cancers, 8 were surgically resected and 3 were treated with combination chemotherapy. In one of the 11 patients (7.7 %), pneumothorax occured after needle aspiration biopsy. No recurrence of tumor in the CT · FNAB needle tract was found during the 4-43 month follow-up period (average 25.1 months). We conclude that CT-guided fine needle aspiration biopsy is very useful in lung cancer patients, when it is difficult to obtain diagnostic materials by bronchoscopic or fluoroscopic biopsy.

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Although an axillary thoracotomy of more than 10 cm has been regarded as the standard approach for spontaneous pneumothorax, such an incision is too large to treat only several small bullae in the apex of the lung. We have developed a new technique to resect bullae through a 3-cm minithoracotomy. 37 patients have been treated by this procedure without recurrence. This technique has the advantage that patients can escape unnecessarily grave operative injury with a cosmetically acceptable wound.
The development of perioperative support, such as unilateral ventilation and a fiberoptic headlight have made our procedure practical.

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A 57-year-old man was admitted with burning pain and swelling of his left arm. A chest X-ray film showed a tumor shadow in the apex of the left lung, squamous cell carcinoma was diagnosed by bronchoscopy and brush biopsy. A sweat test showed a significant decrease in sweating in the distribution from the stellate ganglion through T₃ on the left. The amplitude of the pulse in his left index finger was 4 times that on the right. Our diagnosis was reflex sympathetic dystrophy (RSD). After preoperative irradiation to the tumor (30 Gy), left upper lobectomy was performed followed by left sympathetic ganglionectomy from the lower stellate ganglion through T₃. The burning pain and edema of the left arm disappeared. We conclude that sympathetic ganglionectomy is very efficient in patients with RSD due to lung cancer.

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A 61-year-old-man was admitted to our hospital because of a productive cough for one month. Bronchoscopy disclosed a finely granular squamous cell carcinoma in the right upper bronchus. The tumor invaded the right main bronchus and trachea.
Intrapericardial right pneumonectomy with tracheal wedge resection was performed. Direct pericardial closure was performed, but a pericardial defect, 2×2 cm, remained. On the day after operation, cardiac herniation occurred suddenly after severe coughing. Tachycardia, hypotension, cyanosis, and dilatation of the jugular vein were noted. The electrocardiogram showed atrial fibrillation and R waves at V_3R and V_4R. A chest X-ray film revealed a shift of the heart to the right thorax. The right chest was opened immediately, and the heart was found to have rotated 90 degrees to the right. The heart was returned to its normal position, and the general condition improved immediately. The pericardial defect was repaired with a sheet of PTFE. Repair of the pericardial defect with synthetic material shoud be done in order to prevent cardiac herniation following the intrapericardial pneumonectomy.

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A 54-year-old male with severe respiratory failure (Hugh-Jones IV) caused by bilateral emphysematous bullae, who had been treated conservatively for pneumothorax of the right side for 6 months because of poor pulmonary function, was readmitted to our hospital with pneumothorax of the left side. The left thorax was drained, but an operation was planned three months later when the air leakage continued. Thoracotomy was performed on the right side with large tension bulla, opposite to the left pneumothorax, with the hope that the remaining lung on the right side could expand and that pulmonary function would improv, which might help him to tolerate further surgery.
Recovery was steady. Pulmonary functions and blood gas studies were markedly improved to FVC 2.30l, FEV_1.0 1.13_l, PaO₂ 66.0 torr, PaCO₂ 38.2 torr from the preoperative value of FVC 1.40l, FEV_1.0 0.39_l, PaO₂, 43.4 torr, PaCO₂ 36.2 torr. One year after the operation the patient is able to enjoy his daily life in relatively good condition (Hugh-Jones II).
In conclusion, it is important to perform bullectomy on the side on which the emphysematous change is more serious whether or not pneumothorax is present.

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A 14-year-old woman was admitted to our hospital because of an abnormal mediastinal shadow on her chest X-ray film. Her serum CA19-9 level was 115 U/ml preoperatively. Chest CT and MRI showed that there was a cystic mass containing fluid in the anterior mediastinum. The cystic tumor, measuring 13 ×8×4 cm in size, was resected.
Histological examination showed a mature teratoma, consisting of skin, bronchial epithelium with squamous metaplasia, pancreatic tissue, cartilage, etc. Positive CA19-9 staining was demonstrated in the pancreatic duct and in the bronchial epithelium. After operation, her serum CA19-9 level was 57 U/ml transiently, but it then increased to 180 U/ml. Now, the serum level is gradually decreasing. There have been some reports of mediastinal cystic lesions associated with high levels of CA19-9. But we cannot define precisely the relationship between mediastinal teratoma and CA19-9 in this paticular patient.

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A case of thymoma with hemoptysis and secondary pneumonia required differential diagnosis from primary lung cancer. The patient was a 53-year-old man with complaints of chest pain and hemoptysis. A chest X-ray showed pneumonia-like infiltration in the left upper lobe. About two weeks later, a mass was seen in the anterior mediastinum on chest X-ray as the pneumonia-like density diminished. Although mediastinal tumor invading the lung was suspect-ed, primary lung cancer could not be ruled out by chest X-ray and CT scan. An operative exploration revealed a tumor originating in the left lobe of the thymus with invasion of the pericardium, left phrenic nerve, and left lung. Maximal thymectomy and resection of organs invaded by the tumor were performed. The histological diagnosis was thymoma of the predominantly epithelial cell type.

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